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STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Compassionate Care Hospice of Miami Dade, Inc./CON #10042

18 Aquamarine Avenue Naples, Florida 34114 Authorized Representative: Geoffrey D. Smith (201) 919-4905 HCR Manor Care Services of Florida II, Inc./CON #10043

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

2. Service Area/Subdistrict

District 11, Hospice Service Area 11, Miami-Dade and Monroe Counties B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area 11. However, letters of support were submitted, as discussed below. Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) included 10 letters of support from providers and referrers with its application. These letters were from: Kim Bassett, Chief Executive Officer, Fishermen’s Hospital, Marathon, Florida; Nicki L. Will, PhD., Chief Executive Officer, Lower Keys Medical Center, Key West, Florida; Jack J. Michael, M.D., Chief Executive Officer, Larkin Community Hospital, South Miami, Florida; Robert Linder, Chief Executive Officer,

CON Action Numbers: 10042 & 10043

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Borinquen Health Care Center, Inc.; Aimee Aguiar, M.D., Radiologist, Baptist Hospital System, Miami-Dade County; Martin N. Zaiac, M.D., Dermatologist, Mount Sinai Medical Center, Miami Beach, Florida; Jose A. Orcasita-Ng, M.D.; Physician Family Practice, Hialeah, Florida; Michael Thorpe, M.D., Radiologist, Baptist Hospital System, Miami-Dade County; Regenia Caines, RN, Miami Gardens, Miami, Florida; Gilberto Padin, Administrator, All USA Homes, Inc. (an Assisted Living Facility or ALF), Miami, Florida, and Deborah H. Charron, CIC, Vice President Health Care Practices Group, Seitlin Insurance & Advisory Group, Miami, Florida. These letters generally stated the need for an additional hospice program to meet the needs of the Hispanic population, HIV/AIDS patients, residents of small assisted living facilities and the Jewish community in Miami-Dade and Monroe Counties. The applicant has letters of support in Appendix 3 from the chief executive officers of Fishermen’s Hospital, Lower Keys Medical Center, Larkin Community Hospital and the Borinquen Health Care Center, Inc, indicating the facilities’ willingness to contract with Compassionate Care Hospice for hospice services. Victoria Nursing and Rehabilitation Center’s CEO also expressed his willingness to contract for hospice services. Dr. Jose Orcasita-Ng, M.D. also issued a statement regarding his willingness to refer patients to Compassionate Care Hospice for hospice services as well. The remaining letters of support stated a willingness to network and coordinate with Compassionate Care Hospice in pursing educational opportunities should CON be awarded. HCR Manor Care Services of Florida II, Inc. (CON #10043) submitted seven testimonials and 83 letters of support with its application. The letters of support were from area physicians, health care centers, home health agencies, community businesses, Hispanic residents and business owners, and other HCR ManorCare affiliates. The applicant has letters of support from Heartland Health Care Center of Miami Lakes and Heartland Health Care Center of Kendall that indicate a willingness to contract for inpatient hospice services. Twenty-three letters were from area physicians and the general medical community, 36 letters were from business owners some of which were writing as members and representatives of the Hispanic community. According to the letters of support, the Hispanic community feels that a hospice that is willing to focus on their community’s specific needs and concerns is missing from the current hospice providers in Miami-Dade and Monroe Counties. The applicant also received letters of support from the City Manager of West Miami, Florida, Yolanda Aguilar; Luis C. Morse, Former Deputy

CON Action Number: 10042 & 10043

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Secretary and Acting Secretary for the Florida Department of Elder Affairs; Wilfredo Gort, Chairman of the Hemispheric Congress; Roland Sanchez-Medina Jr., President-Elect, Cuban American Bar Association, Inc.; William Alexander, President, Latin Chamber of Commerce of U.S.A; Daniel Hernandez, President and CEO, Hialeah Chamber of Commerce & Industries; and Barbara Grasch, LMFT, Director of Program Services, Alzheimer’s Association Southeast Florida Chapter. These letters of support indicate a substantial need for an additional hospice provider in Miami-Dade County in order to meet the needs of a growing Hispanic community and that the current hospice offerings are not providing care for everyone who requires hospice services.

C. PROJECT SUMMARY

Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) proposes the establishment of a new hospice program in Hospice Service Area 11, Miami-Dade and Monroe Counties. Compassionate Care Hospice was founded in 1993. Over the past 15 years Compassionate Care Hospice has developed programs in the 12 states of Pennsylvania, New Jersey, Delaware, New York, Massachusetts, Michigan, Missouri, Illinois, Georgia, Texas, South Dakota, and Minnesota. Compassionate Care Hospice does not currently offer services in Florida. The applicant is proposing total project costs of $363,469 with year one operating costs of $3,437,118 and year two costs of $7,021,424. In its Schedule C, the applicant includes the following general statement conditions and proposes nine specific conditions: Compassionate Care Hospice’s General Statement on Willingness to Accept Conditions in Service Area 11 In recent CON applications, many hospice organizations have offered to provide the various required components of hospice services through lengthy listing of numerous specific conditions for award of the CON. As required by law, Compassionate Care Hospice is willing to accept any such conditions on its CON-based on any representations made through this CON application. Compassionate Care will provide all the required components of hospice care, and meet all Medicare Conditions of Participation, and Florida hospice licensure requirements, including the provision of all levels of service (routine home care, continuous care, general inpatient, respite) to all types of patients (cancer, non-cancer, Alzheimer’s, COPD, elderly,


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young adult, pediatric) without regard to race, ethnicity, gender, age, religious affiliation, diagnosis, financial status, insurance status, or any other discriminating factor. Compassionate Care commits to offering excellent quality specialized and individualized programs delivered by a highly qualified interdisciplinary team of professionals, and will implement continuous quality improvement, performance improvement and quality assurance and monitoring programs. The applicant will offer all types of services including physical care and pain management, bereavement counseling and support services (for as long as the bereaved needs such services, without limitation on duration), psycho-social services, spiritual care and counseling, memorial programs and services, palliative radiation and chemotherapy, and massage, music, pet, aroma, and other alternative therapy programs. The applicant will implement a volunteer program and offer a wide array of services through its volunteers. Compassionate Care is finally committed to the continuous and ongoing training, orientation and education of its staff, and will implement specific programs such as tuition reimbursement, ongoing in-services and training programs, library resources, and payment for certification of staff. The applicant will ensure that its staff has the resources, equipment (such as lap tops, PDAs, or other IT equipment) to perform effectively in the delivery of care to their patients and families. Compassionate Care will conduct extensive community education and outreach programs in all communities, including all racial, ethnic or religious minority communities, veterans groups and organizations, and will initiate specialized programs and services to meet the individual needs of such communities in terms of language needs or specialized cultural or religious needs. Examples include such programs as Compassionate Care’s Jewish Hospice Certification; use of a culturally diverse staff; use of bilingual staff; and production of education materials and service forms in Spanish language, Creole language or other languages as needed in the community; and sensitivity and training for the special needs of veterans. Compassionate Care will contribute to the community organizations including universities, community colleges or other organizations involved in the training or health care professionals, or in the delivery of social services to the community.


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Compassionate Care will provide services beyond those mandated and reimbursed by Medicare and Medicaid, including specialized financial assistance to meet the special individualized needs of patients through its charitable foundation, including special “last wishes” of a patient or family, need for specialized equipment not reimbursable, travel for a special family member to visit with a dying patient, or simply need for assistance with mortgage payments, rent, utilities, groceries, or other necessities. Compassionate Care believes that all of the above types of programs, services, policies and protocols should be provided by any hospice provider, and therefore would accept as a condition to its CON application any or all of these general conditions. However, in order to assist the Agency in distinguishing Compassionate Care Hospice from other applicants, the applicant hereby offers the following specific conditions, that are aimed at specific measurable actions that will increase access and quality of care for hospice patients. Specific Conditions: The applicant has agreed to condition award of the CON upon the following: 1. Compassionate Care Hospice commits to opening four office

locations upon commencement of services including one in the north Miami-Dade area; one in the central Miami-Dade area; one in south Miami-Dade County, specifically in the Homestead vicinity; and one in Monroe County in the Marathon area. Compliance will be measured by providing the Agency the location addresses for each office upon commencement of services.

2. Compassionate Care Hospice will reduce severe pain in its hospice

patients within 48 hours of admission to hospice. Compliance may be demonstrated based upon an annual report of Compassionate Care Hospice’s initial pain scores for patients, and recorded pain score after 48 hours. Compassionate Care will achieve a reduction for at least 75 percent of patients with severe pain (score of seven to 10) to a pain score of five or less within 48 hours of admission. This exceeds the Florida requirement in Section 400.60501, Florida Statutes.1

1 Section 400.60501 (1) Florida Statutes requires a minimum that 50 percent of patients who report severe pain on a 0-to-10 scale must report a reduction to five or less by the end of the fourth day of hospice care.


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3. Compassionate Care Hospice will become accredited by the

Community Health Accreditation Program (CHAP) within 24 months of its initial licensure. Compliance will be demonstrated by forwarding a copy of the accreditation to the Agency.

4. Medical directors will access every patient upon admission to

hospice, and will provide patient visits in the home or place of residence. Medical directors will either be board-certified in hospice and palliative care medicine, or will apply for board certification within five years of employment as a medical director. Compliance will be demonstrated through an annual report of the Agency.

5. Compassionate Care Hospice will adopt the following standards

and qualifications for staff: RNs will be encouraged to become certified in hospice and palliative care nursing, and by the third year of operation 50 percent of all supervisory nurses shall attain such certification, with 100 percent of all supervisory nurses attaining such certification by the fifth year of operation; Chaplains shall be Masters of Divinity, with demonstrated completion of an accredited Clinical Pastoral Education (CPE) program; social workers shall be Masters Level and licensed clinical social workers. Compliance with these qualifications will be demonstrated in an annual report to the Agency.

6. Compassionate Care Hospice commits to provide at least 1.5

percent of total patient days as continuous care days, and will have continuous care staff at the bedside within two hours of receipt of a request for such services, and will maintain such service until no longer needed. Compliance will be measured and demonstrated by maintaining records of requests for continuous care, and providing an annual report to the Agency on response times and total patient days.

7. Compassionate Care Hospice will commit that every patient shall

be contacted on a daily basis to determine their needs for the day, and all patients shall receive in-person visits from Compassionate Care Hospice staff at least five times per week for at least two hours per day. Compliance will be monitored by submitting an annual report to the Agency on patient visits.


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8. Compassionate Care Hospice will dedicate one bilingual FTE

marketing coordinator, to be designated as the community education representative who will meet at least once with every licensed ALF provider in Service Area 11 during the first two years of operation. Compliance will be demonstrated in an annual report to the Agency.

9. Compassionate Care Hospice will provide hospice services to

terminally ill inmates in Service Area 11 on an as needed basis, at no cost to the State of Florida. Compliance will be demonstrated in an annual report to the Agency.

HCR ManorCare Services of Florida II, Inc. (CON #10043) proposes the establishment of a new hospice program in Hospice Service Area 11, Miami-Dade and Monroe Counties. HCR Manor Care Services of Florida II, Inc. is a subsidiary of HCR ManorCare, Inc., one of the largest providers of nursing home, assisted living, home health and hospice services throughout the United States. Through its operating group Heartland Home Health and Hospice, ManorCare operates over 100 hospice and home health agencies in 24 states, including seven home health care agencies and one hospice in Florida. HCR ManorCare operates over 300 nursing homes and ALFs in 30 states, including 29 nursing homes and 13 assisted living facilities in Florida. HCR ManorCare operates two 120-bed skilled nursing facilities in Miami-Dade – Heartland Health Care Center Miami-Lakes and Heartland Health Care Center – Kendall and thus is an existing provider in the district with established referral relationships and linkages. The proposed total project cost is $471,825 with year one operating costs of $4,528,026 and year two costs of $7,302,823. The applicant agrees to condition award of the CON upon providing the following: 1. Heartland Hospice commits to establish a primary office location

for District 11 in Homestead or the surrounding area in southern Dade County.

2. Heartland Hospice commits to the development and

implementation of programs focused on improving access to hospice services by Hispanics (and the subgroups within) and persons of Jewish heritage in Service Area 11. The program will include training on cultural differences and competencies and flexible programming to meet their unique needs. Special community education efforts, clinical care protocols, and bereavement services for families will be implemented to increase


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participation in hospice for groups traditionally underrepresented. Programs for other cultural groups will be developed as the needs are identified in the community. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition was met.

3. Heartland Hospice commits to employ bilingual, Spanish-speaking

staff and to provide translated forms and literature. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

4. Heartland Hospice commits to provide specialized training for staff

working with individuals with Alzheimer’s disease to enhance the provision of hospice care to such individuals. Compliance with this condition will be documented by annually providing the Agency with a list of training dates to document that the training has taken place.

5. Heartland Hospice commits to address the specific needs of

patients who have HIV/AIDS and include information in clinical training programs to meet this identified community need. Staff will receive specialized training to enhance the hospice care provided to such individuals. Compliance with this condition will be documented by annually providing the Agency with a list of training dates to document that the training has taken place.

6. Heartland Hospice commits to seek initial accreditation with the

National Institute for Jewish Hospice within two years of opening to better serve Jewish residents of Miami-Dade and Monroe Counties. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

7. Heartland Hospice commits to include representatives from the

Hispanic community on its Community Advisory Board in Service Area 11. The Community Advisory Board will be a volunteer advisory group created to more fully address community issues and will inform Heartland of issues regarding hospice and end-of-life care viewed from the prospective of area residents and businesses (especially within Hispanic and Jewish communities), conduct information sessions as deemed appropriate for the purposes of soliciting further community planned programs and


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services to address service gaps and access issues. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

8. Heartland Hospice commits to develop a Vigil Volunteer program in

Service Area 11, to ensure that patients do not die alone. Vigil volunteers are also available to give support to family members who need a break from the bedside of their loved ones during the dying process. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

9. Heartland Hospice commits to apply for accreditation by the

Community Health Accreditation Program within the first year of opening the proposed office in Service Area 11. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

10. HCR ManorCare, the parent company of the applicant, commits to

develop home health services in Service area 11 in conjunction with the approval of this hospice application. Compliance with this condition is documented by the letter in Appendix 4 stating HCR ManorCare’s intent to develop home health services in District 11.

11. Heartland Hospice commits to providing a minimum of one

educational seminar per quarter focusing on end-of-life issues for professionals who work with end-of-life patients (such as physicians, nurses, religious leaders, etc.). Heartland hospice will commit a minimum of $75,000 over the first two years of operation for this effort. In addition, the applicant will provide a listing of educational materials regarding end-of-life issues at these seminars. Compliance with this condition will be documented by annually providing to the Agency a list of seminars conducted and the dates the seminars were offered.

12. Heartland Hospice commits to establish a patient/family “Special

Needs Fund” of $10,000 for each of the first five years of operation of the Service Area 11 to be used by the clinical team members to meet unusual and uncovered patient and family needs. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.


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13. Heartland Hospice commits that for at least the first five years of operation in Service Area 11, to a minimum annual budget of $15,000 per year for the provision of a special wish fund for hospice patients and families in Service Area 11. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency by the hospice director.

14. Heartland Hospice commits to provide up to $10,000 annually for

tuition reimbursement for employees to continue education in hospice or end-of-life care. This includes tuition reimbursement for Heartland Hospice staff to obtain certified hospice palliative nurse certification, further enhancing the quality of care for hospice residents, as well as supporting staff availability to advance professionally. There will also be an emphasis on promoting tuition reimbursement for the advancement of Hispanic staff. Compliance with this condition will be documented by an annual affirmative statement to the Agency that a tuition reimbursement process is in place.

15. Heartland Hospice commits to contract for 1.0 FTE physician

specializing in palliative care in addition to the medical director, to offer palliative care consults for patients served by Heartland Hospice as well as to hospitals, nursing homes, and other care settings in the community in the fiscal year following Heartland Hospice reaching an average daily census of at least 100 patients. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

16. Heartland Hospice commits to conduct semi-annual meetings with

all contracted hospitals and long-term care facilities to review quality of service and responsiveness. Heartland Hospice will establish a written policy in Service Area 11 to this effect. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

17. Heartland Hospice commits to create and implement a public

education program about the benefits of hospice care in Miami-Dade and Monroe Counties. This program will be similar to the program recently implemented by Heartland Hospice in Jacksonville. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.


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18. Heartland Hospice commits to provide 24-hour, seven days a week,

telephone response provided directly by Heartland staff. HH also commits to provide 24-hour, seven days a week interpretive services, either by Heartland staff or through a contracted interpretive. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

19. Heartland Hospice commits to implement a volunteer program

within the first two years of operation that focuses on groups who traditionally have not been significantly involved in hospice programs such as teens and ethnic and racial minorities. Compliance with this condition will be documented by the annual provision of a records summary to the Agency based on the records kept routinely by the Heartland Hospice volunteer coordinator.

20. Heartland Hospice commits to develop, in year two, a children’s

and family retreat program(s) to serve the residents of Service Area 11. These programs will augment traditional bereavement services especially for children experiencing grief and loss. Compliance with this condition will be documented by an affirmative statement that this program has been developed and the provision of program description to the Agency.

21. Heartland Hospice commits that a pain assessment will be

completed on all patients at time of admission, as part of an ongoing pain management program focused on reducing pain to targeted goals within the first 48 hours of admission. Heartland Hospice will implement existing corporate policies related to pain management as included in Appendix 52. This condition will be documented by annual submission of a declaratory statement that the condition has been met.

Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy and care to the indigent and charity patients. Rule 59C-1.-013(4) Florida Administrative Code contains condition compliance reporting criteria that the Agency uses for an approved CON that has conditions.

2 Attachment 5 contains a detailed generic pain management discussion but is not specific to s. 400.60501 Florida Statutes, hospice treatment requirements.


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D. REVIEW PROCEDURE

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

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

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

1. Fixed Need Pool

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

In Volume 34, Number 40 of the Florida Administrative Weekly, dated October 3, 2008, the Agency for Health Care Administration (the Agency)


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published a need for one hospice program in Hospice Service Area 11 for the January 2010 Hospice Planning Horizon. Hospice Service Area 11 is currently served by Catholic Hospice, Inc., Hospice Care of South Florida, Hospice of the Florida Keys, Inc., Vitas Healthcare Corporation of Florida, HospiceCare of Southeast Florida, Inc., Douglas Gardens Hospice, Inc., and Odyssey Healthcare. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 11, Miami-Dade and Monroe Counties. However, all applicants provide additional arguments in support of need for their projects as discussed below. Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) states that in addition to its reliance upon the published fixed need pool determination of need, it has undertaken its own needs assessment related to specific conditions in Service Area 11 associated with population demographics and dynamics; availability, utilization and quality of like services in the service area; hospice treatment trends; and market conditions. Compassionate Care Hospice's assessment of these conditions includes both quantitative data analysis and interviews with health care providers in the service area whose clients/patients utilize hospice services. The applicant states that the results of its need assessment affirm the Agency's determination that an additional hospice program is needed in Service Area 11. The applicant next discusses specific characteristics of the service area and the manner in which these characteristics impact hospice needs. The factors considered in this assessment include: hospice use rates and trends, population size and composition, mortality rates and other factors and unmet service area needs which are discussed below. Compassionate Care Hospice cites Florida hospice programs admissions totaling 98,619 terminally ill patients during calendar year 2007, which represents 58.8 percent of all Florida resident deaths (167,708)3 during CY 2007. However, the hospice service area with the largest number of deaths (District 11) had only a 43.6 percent admission rate, substantially lower than that of any of the other 26 service areas. Compassionate Care Hospice contends that there are clearly factors, such as its high percentage of Hispanic residents, at work in District 11 (Dade and Monroe Counties) which contribute to its lower admission rate. The applicant contends that the inclusion of Dade and Monroe Counties (hospice service area 11) in the calculation skews the statewide average

3 Office of Vital Statistics 2007 deaths include 167 deaths where county of residence not known.


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downward, which can be seen by comparing the statewide average with District 11 (58.8 percent) to the statewide average excluding District 11 - 60.8 percent, or to the statewide median of 60.0 percent. Compassionate Care Hospice states that state averages and medians merely reflect "typical" performance. Alternatively, the applicant contends that need might better be gauged by comparisons to those areas of the state with the highest admission rates. The applicant included a table on page 17 of its application comparing admissions rate among service areas. This table shows that Service Area 3C had an admission rate of 75.2 percent (31.6 percentage points higher than the Service Area 11 rate). Nine service areas had admission rates of 64.5 percent or above (20.9 percentage points higher than 11) placing them in the top third of all service areas. Service Area 11 ranked last in service area admission rate during calendar 2007 (7.2 percentage points behind the next lowest ranking service area). The applicant contends that a ranking this low can only be justified if there are pronounced market characteristics which work against higher admission rates. The applicant next provides a table showing the Service Area 11 hospice admission trends from CY 2001 – 2007.

Service Area 11 Hospice Admission Trends CY 2001-2007

Year Admits Deaths Admit Rate

2001 6,556 19,765 33.2% 2002 6,862 18,917 36.6% 2003 7,308 19,092 38.3% 2004 7,813 19,052 41.0% 2005 7,605 19,087 39.8% 2006 7,805 18,905 41.3% 2007 8,112 18,607 43.6%

Source: Agency for Health Care Administration Fixed Need Pool Publications for the appropriate years.

The table demonstrates that the admission rate grew from 33.2 percent to 43.6 percent in Service Area 11 during this period. The applicant contends that continuation of this historic growth trend would result in 8,905 hospice admissions in the calendar year 2010 horizon year and an admission rate of 45.1 percent. Compassionate Care contends that while this admissions rate is 1.5 percentage points higher than the 2007 admissions rate within Service Area 11, it is still well below the 2007 rate in all the state’s other hospice service areas. The applicant states that a much higher admissions rate should be attainable in Service Area 11 via the introduction of a new program or programs capable of addressing the various factors which have historically restrained hospice admission rates within the service area.


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A discussion of hospice area 11’s population size and composition with projections to July 2010 is provided. Other factors potentially impacting hospice use are also addressed with separate discussion for cancer deaths, race and ethnicity, hospice appropriate death, and personal income. The applicant concludes that without a focused effort on community outreach hospice use rates admission/penetration rates in Service Area 11 should continue to grow in a manner consistent with the historic trend established over the past seven years. The applicant contends that it has a strong history of service to racial, ethnic and low-income populations; and this background coupled with its aggressive market development plan can push hospice use rates well above the historic trend line. Compassionate Care Hospice contends that Service Area 11 has unmet service needs based on “extensive field work” in which Compassionate Care corporate representatives contacted numerous hospitals, nursing homes, and ALFs by telephone to discuss any concerns they might have with existing hospice services. Compassionate Care Hospice representatives consequently visited hospitals, ALFs, nursing homes and other medical and residential care providers throughout Dade and Monroe Counties. Tab 5 of the application includes a letter from Dee Brock, RN, the Compassionate Care representative, that summarizes her Service Area 11 telephone survey with the conclusions stated above. She also describes her field visit and listed the five hospitals, four nursing homes, five assisted living facilities and The Borinquen Health Care Center, a Federally Qualified Health Center visited. The applicant proposes to condition CON approval to continuous care at 1.5 percent of total patient days. Nationally, continuous care was 0.9 percent of total hospice patient days in 2007 and 0.4 percent in 20064. The applicant contends that four areas of unmet need exist in Service Area 11: • Service Area 11 covers a large geographic area characterized by poor

traffic flow, leading to the need to offer services from a number of office locations to establish a visible, physical presence of hospice provision in different parts of the community.

• Service Area 11 is home to a large elderly prison population lacking access to hospice services.

4 NHPCO Facts & Figures on Hospice Care released October 2008, page 12.


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• There is an enormous number of small ALFs with a very limited awareness or understanding of hospice services, resulting in a lack of care to residents in these settings, as existing providers appear to have focused efforts on the larger institutional ALFs.

• There is inadequate education and community outreach among some hospice care providers to traditionally underserved groups including Hispanic, African-American, and low-income populations.

Compassionate Care Hospice concludes that its analysis of the above factors demonstrate the need for an additional hospice program in Service Area 11 and are the underpinning key aspects of its development plan including the selection of initial office locations; North Miami, Central Miami, Homestead and the Middle Keys (Marathon). The applicant cites the 1999 Florida Corrections Commission annual report published January 1, 2000, which indicated that “Not all terminally ill inmates are suitable for release and that a formal prison hospice program can focus on managing pain, emphasize humane care, and cost less than traditional treatments. The applicant states that Florida still does not have such a program. Recent data indicates that four Florida Department of Correction facilities in Service Area 11 house 6,636 inmates with 22.5 percent or 1,493 considered the elderly prison population. The Department Of Corrections considers elderly inmates to be those age 50 and over. Compassionate Care indicates that according to the Department there were 34 deaths that could have benefited from hospice end-of-life care during the 12-month period ending September 30, 2008. The applicant states that while Florida does not fund hospice care for inmates, Compassionate Care will condition CON approval to providing hospice care to Service Area 11’s terminally ill inmates at no cost to the state. However, the applicant does not demonstrate that it has the support of the Florida Department of Corrections for this proposal. In reference to ALFs, the applicant indicates that there are 957 of these in Service Area 11 and that its telephone contacts and site visit interviews revealed there is a lack of education and understanding of hospice services in the small ALFs. On-site interviews indicate that many of these facility operators do not speak English. The applicant restates its commitment to reach out to these facilities and provide education to ALF owners, operators, residents and families about the benefits of hospice care. Compassionate Care indicates that they believe one of the reasons for the overall stagnation in Miami-Dade hospice admissions is that most hospice providers fail to reach out beyond the


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easy to reach skilled nursing facility and hospitals. Compassionate Care indicates that it will not only have written flyers and materials in English and Spanish, but will send bilingual representatives to ALFs to establish working relationships. The analysis culminates in a utilization forecast for the proposed program which is based on the aggregate experience of hospice programs initiating operations in Florida beginning in CY 2002 (market shares provided on page 35 table), size of the Service Area 11 market and Compassionate Care Hospice’s market plan. Compassionate Care concludes that it will have 374 admits in CY 2010 (year one), 708 in year two, 885 in year three and 1,064 in year four, with its market share starting at 4.2 percent increasing to 11.3 in year four. HCR Manor Care Services of Florida II, Inc. (CON #10043) projects that it will serve 321 hospice patients in year one of operations, 437 in year two, and 502 in year three based on what it refers to as the Florida experience and the experience of the existing hospice providers in Service Area 11. The applicant has identified the following as aspects that assist in evaluating need in Service Area 11: demographic trends, historical utilization of hospice services, potential to increase penetration rates in Service Area 11, special needs populations, and projected growth in hospice demand. Based on the analysis of the above aspects, the applicant contends that it has identified three special populations in Miami Dade and Monroe counties that are underserved, Hispanics, individuals with HIV/AIDS, and individuals with Alzheimer’s disease. The applicant states that in 2008, Miami-Dade and Monroe counties population aged 65 and older represents 13.7 percent of the total population and is projected to represent approximately 15 percent of the population by 2014. This segment of the population is expected to increase by 47,550 between 2008 and 2014. The applicant also contends that while the under 65 population is only increasing at a rate of 0.7 percent, it is still a reasonable level of growth; the incremental growth between 2008 and 2014 will be 94,736, individuals which nearly doubles the absolute growth in the 65 and over age cohort. The applicant concludes that the increase in both the under 65 and the 65 and over age populations indicate that a hospice provider must be prepared to meet the needs of both age categories. The applicant completed a projection of population growth in Miami-Dade and Monroe counties by race and ethnicity. Through its analysis, the applicant contends that non-white populations are growing at a faster rate than whites, although whites comprise a substantial majority


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of the population5. When analyzing ethnicity, the applicant contends that while the growth rate in the age cohort 65 and over is considerable for all ethnicities, it is most notable in the Hispanic population. Hispanic residents over age 65 are estimated to have increased by 21.6 percent (185,943 in 2000 to 226,078 in 2007) while Hispanic residents under age 65 are estimated to have increased 17.3 percent (1,200,308 in 2000 to 1,407,418 in 2007)6. The applicant contends that the trend in deaths by ethnicity reflects the growth in the overall Hispanic population in the service area. Overall, non-Hispanic deaths actually decreased 10.3 percent (9,104 in 2002 to 8,165 in 2007), while people of Hispanic heritage experienced an increase of 8.5 percent in deaths (9,564 deaths in 2002 to 10,376 deaths in 2007). The applicant examined causes of death and found that while the number of total deaths has been decreasing over the past several years, there was a rise in HIV/AIDS related deaths among Hispanics. Deaths due to HIV/AIDS decreased annually by one percent from 2002 to 2007 (from 389 deaths to 377), but Hispanic deaths due to HIV/AIDS increased by three percent, hitting a peak in 2006 with 131 deaths (73 deaths in 2002 to 83 in 2007)7. The applicant states that according to the Florida HIV/AIDS Annual Report 2007, analysis of county-specific AIDS case rates per 100,000 population for 2007, Miami-Dade county ranked second to the highest with a rate of 39.2 AIDS cases per 100,000 population. Miami-Dade County, however, ranked first with the highest number of HIV cases in the state with 25 percent of total cases, according to the applicant. The applicant also examined Alzheimer’s disease deaths and found that deaths due to Alzheimer’s disease increased annually by one percent from 2002 to 2007 (448 deaths to 479), while Black and Hispanic deaths due to Alzheimer’s disease experienced the most growth, seven percent (31 deaths to 43) and three percent (271 deaths to 313) respectively8. The applicant notes that Service Area 11 ranks last among all service areas in hospice penetration and states that there is clearly potential to increase hospice penetration rates in the service area through greater

5 Exhibit 7, page 41, CON Application #10043: Projected Population for Miami-Dade and Monroe Counties by Race and Annual Rate of Change, 2008-2013. 6 Exhibit 8, page 42, CON Application #10043: Population of Miami-Dade and Monroe Counties in 2000 and 2007. 7 Exhibit 12, page 45, CON Application #10043: Trends in HIV/AIDS Deaths in Miami-Dade and Monroe Counties by Race and Ethnicity. 8 Exhibit 13, page 46, CON Application #10043: Trends in Alzheimer’s Disease Deaths in Miami-Dade and Monroe Counties.


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patient education and outreach to referral sources. The applicant partially attributes this low penetration rate to a lack of access to Hispanic residents, who comprise 60.1 percent of the area population. Projected market shares were applied to the projected total hospice admissions to calculate the number of admissions by category and age that Heartland will serve. Rates are generally based on the experience of other hospices in Florida. The applicant states its market shares are expected to range from 3.6 percent in 2010 to 4.5 percent in 2012, which it considers to be reasonable. The applicant states that the average lengths of stay are expected to be 63, 80, and 96 days in 2010, 2011, and 2012 respectively. The applicant contends that the lengths of stay are consistent with other hospices in Florida9.

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

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

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

commitment to serve populations with unmet needs.

Neither applicant clearly demonstrates that any population in the service area had unmet needs. Each applicant is responding to published need for an additional hospice program for the January, 2010 planning horizon.

Each applicant discusses serving populations they believe to be underserved. Compassionate Care Hospice of Miami Dade, Inc. (CON

#10042) commits to serve populations with unmet hospice needs and to specifically target the areas of highest unmet hospice need. According to the applicant, areas of highest unmet need as identified in its market assessment of the service area include: care for terminally ill prison inmates and a lack of service to residents of the area’s large number of small ALFs. The applicant states that over 20 percent of prison inmates in Miami-Dade are defined as elderly and a sizeable number of prisoners become terminally ill and die within the system each

9 Calculations based on Exhibits 18 and 19, pages 64 and 65, CON Application #10043.


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year. Funds are not available to contract for services to this population and existing hospices have not stepped forward to meet this need. The applicant also states that there are 957 ALFs in Service Area 11 and that existing hospice providers have not provided outreach and education to these ALFs resulting in a lack of understanding of hospice among these providers and a subsequent lack of care to residents in this setting. The applicant states that it has received strong commitments of support from three area acute care hospitals which include commitment to contract for inpatient hospice services. Compassionate Care states that it has adopted an aggressive market development plan that calls for the establishment of three geographically distributed office locations in Miami-Dade County upon initiation of operations, including an office in the Homestead area. The applicant states that an additional office will be established in the town of Marathon to serve Monroe County residents. HCR Manor Care Services of Florida II, Inc. (CON #10043) states that through its analysis there are significant unmet needs in hospice Service Area 11 with particular need demonstrated for Hispanic patients, chronically ill patient populations with Alzheimer’s disease, and patients with HIV/AIDS. The applicant states that under-service to the Hispanic population is identified through the proportionately low numbers of hospice patients in District 11 compared to the population percentage and the non-Hispanic hospice utilization rate. The applicant also states that demographic trends including population growth rates and increasing number of deaths also support the need for greater services to the Hispanic population. Heartland hospice commits to address the specific needs of patients who are Hispanic and include information in clinical training programs to meet this identified community need. Heartland states that it will also ensure that the community is made aware of their acceptance of Hispanic patients through their community outreach and education programs. Heartland intends to meet the needs of the underserved in District 11 by establishing an office in the Homestead area to serve both Miami-Dade and Monroe Counties.


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Heartland states its proposed marketing and public outreach efforts for hospice care will improve access throughout the district, reaching minorities and other patient populations in need. Heartland states it will meet the needs of the Hispanic population by providing special programs that cater to this population, to include support from, or involvement of, bilingual, Spanish speaking staff and translated literature and forms. These programs will include special community education efforts, clinical care protocols, and bereavement services for families in order to increase participation in hospice for groups traditionally underrepresented. Heartland hospice will pay particular attention to systematic outreach, education, support groups and recruitment of volunteers and staff in the Hispanic community. The teen and minority volunteer program will recruit Hispanic teens to assist with this effort. Marketing materials, relevant forms and program information in Spanish will be utilized and prepared specific to the services in District 11. The applicant states that the number of deaths supports the demand for greater care for HIV/AIDS and Alzheimer’s. Heartland Hospice states it will meet the growing need by providing specialized training for staff working with individuals with these diseases to enhance the provision of hospice care to such individuals. Heartland Hospice states that it has developed care strategies for Alzheimer’s patients that integrate complementary therapies such as massage and music therapy with traditional palliative care. Heartland states it will provide comprehensive training for its staff with regard to Alzheimer’s patients10. The applicant states it is involved in the AHOPE project which is a measure of symptom severity that was specifically developed to assess the six-month prognosis of late stage Alzheimer’s patients in order to obtain a more timely admission to hospice. The applicant states that the AHOPE measure was tested through research at the University of Colorado at Denver and Health Sciences center, School of Nursing, with dementia patients in long-term care settings. Heartland states it has participated for two years in the AHOPE validation research, most recently involving individual hospice offices across the country.

10 Appendix 3 provides information on the Guide to Understanding and Caring for Persons with Alzheimer’s disease, which is a training manual for Heartland staff, CON Application #10043.


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Heartland makes a commitment to serve these populations with unmet needs and will ensure all populations, including minorities, are educated about the benefits of hospice care through community educational seminars distribution of multi-lingual educational materials, and direct counseling utilizing trained staff and volunteers. The applicant states that members of the hospice care team will also become involved and coordinate educational events with the local chapter of the Cancer Society, Heart Association, and Alzheimer’s Association and others.

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

Compassionate Care Hospice of Miami Dade, Inc. (CON

#10042) expects to provide approximately 1.3 percent of its total patient days to inpatients during the first two years of operation in Service Area 11. Inpatient care is to be provided through contractual arrangements with existing hospitals and nursing homes. The applicant states it has secured letters from the Chief Executive Officers of Fisherman’s Hospital, Lower Keys Medical Center, and Larkin Community Hospital stating their willingness to enter into agreements to provide inpatient care. The applicant states it typically contracts with a number of hospitals and nursing homes in its various service areas in order to assure appropriate geographical accessibility. Compassionate Care Hospice anticipates that it will negotiate contractual arrangements with hospitals and nursing homes in all geographic areas of the service area. The applicant also has letters of support indicating a willingness to contract for inpatient services from the Borinquen Health Care Center and Victoria Nursing and Rehabilitation Center. HCR Manor Care Services of Florida II, Inc. (CON #10043) proposes to provide the inpatient care component of its hospice program through contractual arrangements with existing health care facilities, including the acute care hospitals in the service area, and skilled nursing facilities. A letter of intent to contract for beds is provided by other Heartland facilities - Heartland Health Care Center-Miami Lakes and Heartland Health Care Center of Kendall. The applicant states that the facilities are poised to assist


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the hospice when implementation begins, which the applicant feels affirms its commitment to ensuring access to inpatient care and the continuum of care model11. The applicant states that building on its experience in establishing relationships with nursing homes and ALFs, it will quickly create mutual partnerships to better serve hospice patients.

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


#10042) states that they are committed to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS. The applicant states that this commitment is evidenced by the existing admissions policy and by the Compassionate Care related entities history of provision of care to these populations. The applicant provides a table outlining the living status of its patients during 2006, the most recent period for which system-wide data have been aggregated. Compassionate Care Hospice states it delivers 11 percent of its care to patients who either live alone or with a compromised caregiver, including nearly nine percent (8.7 percent) to those living alone. In addition, the applicant states it has provided care to individuals in boarding homes, homeless shelters, psychiatric centers, and correctional facilities. The applicant states that it does not require that a patient have a caregiver in the home to be part of their program. Compassionate Care also states it serves all patients including those who live alone, are transient, have AIDS, or are homeless. Compassionate Care Hospice states that if a homeless patient is discharged from the hospital needing hospice care with nowhere to go, it will place them in an inpatient unit and apply for Medicaid. Once the patient qualifies and receives Medicaid, they will be placed into a long-term care environment in which hospice care can still be provided as long as the patient requires it.

11 Letter of contractual agreement appear in Appendix 10, CON Application #10043.


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However, the process of qualifying the homeless for Medicaid can be difficult. One way in which the homeless can receive Medicaid is by qualifying for Supplemental Security Income (SSI) benefits through social security. Once becoming eligible for SSI, Medicaid coverage is a benefit of the program. In most cases, the hospital will initiate the process of applying for SSI and Medicaid in order to receive payment for services. The homeless can receive SSI for six months out of every nine months they stay in a public (government run) emergency shelter. There is no time limit on getting SSI in a private shelter. HCR Manor Care Services of Florida II, Inc. (CON #10043) states that it is committed to serving patients who do not have primary caregivers at home; the homeless; and patients with AIDS, by having a longstanding policy that states the company’s commitment to such patients. When a hospice patient can no longer care for him or herself, the Hospice’s Plan of Care works with the individual to assure that a primary caregiver can be designated. With the relationship among nursing homes and ALFs each person can be placed so that the patient benefits from hospice care. A lack of a home or a primary caregiver will not result in a person foregoing the hospice benefit. The applicant states that in order to ensure continuity of care, the hospice RN will contact the primary care physician to discuss the need to admit to respite, inpatient, or outpatient, and obtain the order12. Heartland Hospice commits to provide hospice services to all, without discrimination: “Heartland Hospice will not discriminate on the basis of ability to

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

or other category that may classify a person as medically

underserved. The proposed hospice services will be provided to all

hospice appropriate patients based on physician orders and the

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

day/7 days per week.

12 Refer to Appendix 20 for the plan for primary care giving and intake form CON Application #10043.


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HCR Manor Care Hospice will admit and treat all persons without

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

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

distinction in the manner of providing palliative care to terminally ill

persons and their families.

Admissions will not be refused nor services discontinued or

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

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

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

Medicaid will be admitted in accordance with NHO criteria.

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

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

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

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

inpatient or outpatient and obtain the order.

Medically indigent individuals are defined as persons who do not

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

healthcare benefits payments program and who do not have the

resources and ability to pay for their care. Medically indigent

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

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

will not discriminate against the ability to pay for services being

rendered.13” In addition, the applicant commits to address the specific needs of patients who have HIV/AIDS and include information in clinical training programs to meet this identified community need. Heartland states it will ensure that the community is made aware of its acceptance of HIV/AIDS patients through its community outreach and education programs. Staff is to receive specialized training to enhance the hospice care provided to such individuals.

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

Hospice Service Area 11 consists of two counties, Miami-Dade and Monroe. This criterion is not applicable to this review.

13 A copy of HCR policy is included in Appendix 19 CON Application #10043.


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


#10042) states that it currently provides those services needed by the community to patients regardless of their payer status and in many cases regardless of their legal status. The applicant further states that a significant portion of services that are not specifically covered by private insurance, Medicaid, or Medicare are provided by its programs. On a combined basis in 2006 the applicant states its programs provided 2.8 percent of all days of care to patients that were identified as being unable to pay. This proportion is expected to be 2.2 percent in Service Area 11. In addition to providing its full range of services to patients not covered by private insurance, Medicaid or Medicare, Compassionate Care offers a variety of services that are not included in the range of services typically reimbursed by these programs. The applicant proposes to provide the following non-covered services: • Bereavement - Bereavement support and grief counseling are

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

• Compassionate Care Hospice Foundation - Compassionate Care

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

• Compassionate Courage - Compassionate Courage offers a safe

place for children to express their feelings and share with others who have also experienced a loss. Compassionate Courage programs provide bereavement support groups for elementary and middle school children who are dealing with a significant loss. The foundation’s activities typically assist these patients and families through services not generally covered or reimbursed by insurance or government payers.


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• Complementary Therapies - Complementary therapies are

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

HCR Manor Care Services of Florida II, Inc. (CON #10043) has agreed to condition this application with a commitment of a patient/family “Special Needs Fund” of $10,000 for the first year of operation of the Service Area 11 hospice specifically designated as money for programs and services outside of Medicare hospice benefit. Such programs may include medical transportation, private duty care givers, housing, burial funds, music/pet therapist and massage/alternative therapies. The applicant states that in addition to the core hospice services, including continuous care during periods of crisis and bereavement services, Heartland Hospice has established a program of Caring Promises that is currently employed by the hospice in Subdistrict 4A. The Heartland Caring Promises are as follows: • We promise to care for the mind, body, and spirit. • We promise to provide care that is comforting and

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

they are in life’s journey.

Heartland Hospice offers a Children’s Grief Camp, “Camp Heartland” to provide an outlet for children of ages three to 15 to express themselves and ease their grief. Activities include horseback riding, pet therapy, basketball, beadwork, swimming,


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hayrides, camp fires and dancing. The children also make “memory boxes” in memory of their loved one, and participate in a balloon release memorial service. The applicant commits to develop, in year two, a children’s and family retreat program to serve the residents of Service Area 11. According to the applicant, these programs will augment traditional bereavement services especially for children experiencing grief or loss. Heartland states it has also implemented several community bereavement programs throughout the nation with grant funding from the Hospice Memorial Fund, including: • Bereavement support groups for teens works in conjunction

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

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

• Hospice educational materials are distributed to schools and

community agencies. A training program is conducted in schools for guidance counselors and social workers.

• A public education program about the benefits of hospice care

in Miami-Dade and Monroe Counties. The goal is to raise awareness and understanding of patients and families regarding hospice care as an end-of-life option.

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


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

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

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

(a) Proposed staffing, including use of volunteers.


#10042) states it will provide sufficient staff to meet or exceed the recommendations of the National Hospice and Palliative Care Organization. Compassionate Care’s staffing schedule indicates 39.94 FTEs in year one and 74.4 FTEs in year two14. The applicant states that it has consistently met or exceeded the Medicare conditions of participation requirement that hospices provided a minimum of five percent of direct patient care or administrative staff hours through volunteer personnel. Compassionate Care Hospice states it will utilize an interdisciplinary team model for providing care to its patients and families. The applicant states that by including a wide range of personnel skills and experience and input from the family, Compassionate Care Hospice believes that the patient and the family are the primary unit of care. Other members of the care team include: patient’s primary hospice physician, hospice medical director, registered nurse, social worker, certified home health aides/nursing assistants, therapists (to be utilized on a contractual basis), dieticians (to be utilized on a contractual basis), chaplains and bereavement counselors. Additional staff will be added as needed. HCR Manor Care Services of Florida II, Inc. (CON

#10043) states that the initial office will be fully staffed with an office manager, clerical support, director of professional services/patient care coordinator, and appropriate field staff. This proposed hospice program will follow the same staffing patterns that have served patients well in numerous other communities. The applicant listed the following as its standards of staffing: 1.0 FTE registered nurse and home

14 Staffing Schedule provided in Schedule 6A, CON Application #10042.


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health aide per 12 census, 60-70 percent of RN, HHA staffing should be full-time employees, 1.0 FTE admissions nurse to do a minimum of 10-12 admissions per week, 1.0 FTE medical social worker per 25-30 census, 1.0 FTE administrator, 1.0 FTE office manager, 1.0 FTE clerical staff per 25 census (includes office manager, team coordinator, and receptionist, etc.) 1.0 FTE director of professional services, patient care coordinator per 50 census, 1.0 FTE Chaplain per 50 census, 1.0 FTE volunteer coordinator per 100 census, and 1.0 FTE bereavement coordinator per 80 census. The applicant states that it will employ a full-time volunteer coordinator for every 100 patients. Through the company’s existing network and initial public awareness campaign’s, Heartland Hospice expects no difficulty in recruiting the volunteers needed for the new hospice based on its successes in numerous other communities. HCR ManorCare states it will provide volunteer orientation and ongoing training to ensure that volunteers have the skills needed to assist patients and their families.

(b) Expected sources of patient referrals.


#10042) states that patient referrals are expected to come from numerous sources, including physicians, hospital social workers and case managers, long-term care facilities, other community-based agencies, family members and others. The applicant states that initially hospitals, nursing homes, physicians and ALFs will constitute the bulk of anticipated referrals. The applicant has identified small ALFs as a particular point of community outreach and education emphasis. The applicant states that it has initiated contracts with major health care providers throughout hospice Service Area 11 and will continue to develop these relationships following approval. The applicant anticipates that appropriate referral relationships will be in place upon project initiation in January 2010. Fisherman’s Hospital, Marathon, Florida, Lower Keys Medical Center, Key West, Florida, Larkin Community Hospital, South Miami, Florida, and Victoria Nursing and


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Rehabilitation Center, Miami, Florida have provided letters of support stating their willingness to contract for general inpatient hospice services with the applicant should they be awarded the certificate of need. HCR Manor Care Services of Florida II, Inc. (CON

#10043) states that it will target a variety of sources for hospice referrals such as physicians, hospital discharge planners, social workers, nursing facilities, ALFs, home health agencies, community social service agencies, churches, and veterans groups. The applicant received several letters of support for the project from local physicians that expect to refer patients to Heartland Hospice. Patients and families may also refer themselves with the support and direction of an attending physician. HCR Manor Care also plans to conduct a variety of marketing activities to let the community know of its presence as a hospice provider in the service area and has reserved a considerable portion of the funding for this project for community outreach initiatives. Heartland received letters of support from Heartland Health Care Center – Miami Lakes and Heartland Health Care Center – Kendall stating their willingness to contract for inpatient hospice services.

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


#10042) states its commitment to providing hospice services to all appropriate patients regardless of their ability to pay. The following table delineates the number of admissions by payer type for the first two years of operation.

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

Service Area 11 Payer Type Year One Year Two

Medicare 285 586

Medicaid 19 26

Private Insurance 51 70

Self-Pay/Indigent 19 26 Total 374 708 Source: CON Application #10042, page 50.


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As shown in the table above, the applicant intends to serve 374 and 708 patients in its first and second year of operation respectively. It is noted that the applicant’s provision of Medicare will comprise 80.49 percent of admissions during the first two years of operations, while Medicaid and indigent/self-pay will each comprise 4.15 percent. HCR Manor Care Services of Florida II, Inc. (CON

#10043) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation. However, the applicant actually provided the payer types by number of patient days, not admissions as stated in the table submitted by the applicant.

Projected Number of Admissions by Payer Type For HCR ManorCare Services of Florida II, Inc.


Medicare 18,202 31,466

Medicaid 1,394 2,409

3rd Party Insurance 223 385

Self-Pay 202 350

Charity/Other 202 350 Total 20,223 34,960 Source: CON Application #10043, page 96.

The table below is from the applicant’s supporting worksheet two to Schedule 7A:

Projected Number of Admissions by Payer Type For HCR ManorCare Services of Florida II, Inc.


Medicare 272 371

Medicaid 27 37

Commercial Insurance & HMO/PPO 8 10

Self-Pay 7 9

Charity/Other 7 9 Total 321 437 Source: CON Application #10043, Schedule 7A supporting worksheet 2.

The applicant projects Medicare will comprise 84.82 percent of admissions, Medicaid 8.44 percent and indigent/self-pay 4.22 percent during the first two years of operations.


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

illness, for the first two years of operation.


#10042) provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For Compassionate Care Hospice of Miami Dade, Inc.

Service Area 11 Disease Year One Year Two

Cancer 128 243

Non-Cancer 246 465 Total 374 708 Source: CON Application #10042, page 50.

The applicant projects to serve 374 patients in year one and 708 patients in year two. HCR Manor Care Services of Florida II, Inc. (CON

#10043) provided the following table illustrating the projected number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For HCR ManorCare Services of Florida II, Inc.

Service Area 11 Disease Year One Year Two

Cancer 117 159

Other 204 278 Total 321 437 Source: CON Application #10043, page 96.

The applicant projects to serve 321 patients in year one and 437 patients in year two.

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


#10042) provides the following table for the projected number of admissions by age cohort.


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Projected Admissions by Age Group for

Compassionate Care Hospice of Miami Dade, Inc. Service Area 11

Under 65 Over 65 Total

Year One 65 309 374

Year Two 122 586 708

Source: CON Application #10042, page 50. HCR Manor Care Services of Florida II, Inc. (CON

#10043) provides the following table for the projected number of admissions by age cohort.

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

Service Area 11 Under 65 Over 65 Total

Year One 55 266 321

Year Two 74 363 437

Source: CON Application #10043, page 96.

(f) Identification of the services that will be provided

directly by hospice staff and volunteers and those that will be provided through contractual arrangements.

The hospice care team shall directly provide the following core services: nursing services, social work services, pastoral or counseling services, dietary counseling, and bereavement counseling services. Physician services may be provided by the hospice directly or through contract. A hospice may also use contracted staff if necessary to supplement hospice employees in order to meet the needs of patients during periods of peak patient loads or under extraordinary circumstances. Compassionate Care Hospice of Miami Dade, Inc. (CON

#10042) asserts that it will provide the core services (physician services, nursing services, social work services, dietician/nutritionist services, bereavement, pastoral and counseling services, etc.) directly through hospice staff and volunteers. Compassionate Care states it intends to also offer non-core services that will be provided through contractual arrangement such as: physical, occupational and speech therapy, massage therapy, music therapy, inpatient and respite services, infusion therapy, and patient transportation services.


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HCR Manor Care Services of Florida II, Inc. (CON

#10043) asserts that with the exception of physicians, hospice core services will be provided by the hospice care team, including volunteers. When needed, contract services are determined on an individualized basis by the interdisciplinary team and/or medical director in consultation with the patient, family and attending physician. The applicant indicates that contract services are authorized in advance and provided with the ongoing awareness and input of multidisciplinary team. The multidisciplinary team consists of: • Medical Director and attending physician • RNs and LPNs (hospice staff) • Social workers (hospice staff) • Home health aide (hospice staff) • Physical therapists/assistants (contract) • Occupational therapists/assistants (contract) • Speech and language pathologists (contract) • Paraprofessionals (homemakers, companions, aides)

(hospice staff) • Spiritual counselors (hospice staff) • Pharmacist (contract) • Registered dietitians (hospice staff) • Bereavement Coordinators (hospice staff)

(g) Proposed arrangements for providing inpatient care.


#10042) states it expects to provide approximately 1.3 percent of its total patient days to inpatients during the first two years of operation. The applicant states that inpatient care services will be provided through contractual arrangements with existing skilled nursing facilities and hospitals within Service Area 11. The applicant provided evidence of local support for the project and its ability to secure contracts for services in Appendix 3 of the application. This evidence of local support and willingness to contact for inpatient hospice services was received from Larkin Community Hospital, Fishermen’s Hospital, Lower Keys Medical Center, Victoria Nursing and Rehabilitation Center, and the Borinquen Health Care Center.


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#10043) will initially arrange for providing inpatient care through contractual arrangements with hospitals and nursing homes. Heartland Hospice has received letters of intent from Heartland Health Care Center- Miami Lakes and Heartland Health Care Center Kendall to contract for the provision of inpatient beds, as shown in Appendix 10. The applicant does not propose to construct a freestanding inpatient hospice facility at this time. The applicant states that hospice care will be under the direct administration of the hospice, whether the inpatient facility is located in a nursing home or a hospital. The applicant provided evidence of local support for the project and its ability to secure contracts for services.

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


#10042) did not provide a number of expected inpatient beds but rather states that it intends to enter into contractual agreements with nursing homes and hospitals to provide inpatient care to hospice patients when needed. The applicant further states that it is not proposing to construct a freestanding inpatient hospice facility but instead will utilize existing beds in the service area. The applicant anticipates 1.3 percent total patient days to inpatient care resulting in a low daily inpatient census of about one bed per day during year one, and about two for year two. HCR Manor Care Services of Florida II, Inc. (CON

#10043) did not provide a number of expected inpatient beds but rather proposes to contract for inpatient beds with existing providers.

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


#10042) states that patients are admitted to an inpatient bed according to the guidelines set forth in the federal Medicare guidelines for hospice inpatient care. The interdisciplinary team is responsible for identifying and


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recommending patients who meet general inpatient hospice criteria and admission decisions are made on an individual case by case basis after evaluation by the hospice interdisciplinary team and in consultation with the patient’s attending physician. Compassionate Care states that it will also provide respite care for when the patient’s family/caregiver needs a short period of relief. This will be offered on an “as needed” basis for a maximum of five days per respite admission for a Medicare/Medicaid patient. For patients covered by other insurers, the duration may be approved for a longer period of time. HCR Manor Care Services of Florida II, Inc. (CON

#10043) states that inpatient care is dictated by a patient’s medical need. If possible, symptoms are addressed in the patient’s home environment. Occasionally this is not possible due to the nature of the symptoms, the level of care giving support available, or patient or family wishes. The applicant states that at that point, hospice patients are encouraged to seek the level of care with which they are most comfortable, up to and including inpatient hospice care. Based on their need, inpatient, residential or an alternative mode of care is provided.

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


#10042) states it is committed to serving patients who do not have primary caregivers at home, the homeless and patients with AIDS in its proposed program in service area 11. Compassionate Care Hospice does not require that a patient have a caregiver in the home to be part of their program. According to the applicant, in 200615 it served 549 patients that lived alone which totaled about 8.7 percent of its total patients. In addition to serving patients who live alone, with no caregiver, the Compassionate Care group states it served 140 patients during 2006 that lived with a compromised caregiver.

15 Data for 2007 was used for Compassionate Care Hospice Atlanta, which according to the applicant was too new to have data available for 2006.


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Compassionate Care Hospice states that if a homeless patient is discharged from the hospital needing hospice care with nowhere to go, it will place them in an inpatient unit and apply for Medicaid. Once the patient qualifies and receives Medicaid, they will be placed into a long-term care environment in which hospice care can still be provided as long as the patient requires it.

However, the process of qualifying the homeless for Medicaid can be difficult. One way in which the homeless can receive Medicaid is by qualifying for SSI benefits through social security. Once becoming eligible for SSI, Medicaid coverage is a benefit of the program. In most cases, the hospital will initiate the process of applying for SSI and Medicaid in order to receive payment for services. The homeless can receive SSI for six months out of every nine months they stay in a public (government run) emergency shelter. There is no time limit on getting SSI in a private shelter. HCR Manor Care Services of Florida II, Inc. (CON

#10043) states that they will work with patients to develop a plan to get them the care they need, when they are no longer able to care for themselves. Heartland also states that when a hospice patient can no longer care for himself, the plan of care requires a primary caregiver at the home or admission to a long-term care facility or an alternate place where the patient’s safety can be secured.

(k) Arrangements for the provision of bereavement services.


#10042) states that it will provide bereavement services to the surviving family members, for up to 15 months as needed after the patient’s death. Bereavement services will begin with an initial bereavement risk assessment to be completed by the social worker, bereavement coordinator or designee within three days of admission or at the earliest convenience of the patient/family/caregiver. The applicant states that the bereavement coordinator may also provide supportive counseling prior to the death of the patient but within two weeks after the death of the patient a sympathy card will be sent to the bereaved. Bereavement counselors will work with patients and families to assist with coping, grief work, and bereavement care and teach grieving families how to find healthy paths to healing. The applicant states it


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also provides bereavement support for children, called Compassionate Courage. The children participate in art activities, age appropriate reading, poetry, writing exercises, group discussions, drawings, memory collages, a “feeling toss” and books. HCR Manor Care Services of Florida II, Inc. (CON

#10043) indicates that it has a strong commitment to providing bereavement services both to its surviving family members and the community at large. HCR Manor Care plans to employ a full-time bereavement coordinator (one per 80 census) in order to establish the types of bereavement programs that are provided throughout its national network of hospices. The applicant also proposes a children’s and family retreat program to be developed to augment traditional bereavement services, especially for children experiencing grief or loss.

(l) Proposed community education activities concerning hospice programs.


#10042) states that it tailors its services and program offerings to the unique needs of the communities in which it serves. Compassionate Care asserts that it is committed to providing community education activities concerning hospice programs to residents of Service Area 11. The applicant states that through visits with hospital, nursing home, and other institutional providers in the area there is a need for more staff in-service training and educational opportunities regarding the goals and objectives of hospice care, and how the hospice team best interacts with the facility team. The applicant states it will provide quarterly in-services at each hospital and nursing home and Compassionate Care representatives will meet individually with the administration of each licensed facility provider at least once each month to determine in-service training needs. Some of the community education activities will include:


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• Community education programs on overview of hospice,

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

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

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


#10043) states that its community education activities include meeting one-on-one with physicians and other health care professionals as well as formal educational programs. The applicant commits to provide a minimum of one educational seminar per quarter focusing on end-of life issues for professionals who work with end-of-life patients (such as physicians, nurses, religious leaders, etc.). In order to support this effort, the applicant also commits $75,000 over the first two years of operation. Formal programs include: frequent programs for the community addressing living with the loss of a loved one; presentation to Alzheimer’s support groups; guest lecturing at schools, churches, and professional organizations; distribution of educational materials to schools and community organizations; and publication of articles of interest and of education in local community newspapers. The applicant is proposing a considerable marketing campaign to launch its hospice into the service area and foster community support through regular and frequent educational seminars. By educating the public about the benefits of hospice care, utilization is expected to increase for all hospice providers in the area. In addition, the applicant commits to the development and implementation of programs focused on improving access to hospice services by Hispanic residents in Service Area 11.

(m) Fundraising activities. Compassionate Care Hospice of Miami Dade, Inc. (CON

#10042) states that it participates in fundraising activities through its Compassionate Care Hospice Foundation. Compassionate Care Hospice Foundation, Inc. is a non-profit organization located in Newark Delaware which provides financial assistance to terminally ill patients and families in need. Additionally, it supports public programs to provide


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the general public with information about the end-of-life choice so that individuals can determine their wishes and help their families prepare for future events16. Compassionate Care Hospice Foundation does not use contributions to provide direct hospice care; but rather, it is there to help when financial difficulty is overwhelming and places an added stress on terminally ill patients and their families. The applicant states that the foundation provides services that are generally not covered or reimbursed by insurance. These may include such actions as making rent, mortgage or utility payments on behalf of individuals or families, funding special projects, volunteer efforts, and education programs designed to benefit the community by raising awareness about hospice care. The applicant states it expects to have limited fundraising activities in Service Area 11. However, Compassionate Care states it will engage in soft solicitation of support from the families and friends of those it has served. Gifts to the hospice, memorials, and other voluntary contributions, such as specifying a donation to the hospice in lieu of flowers at a funeral provide ways by which Compassionate Care may access outside funds. HCR Manor Care Services of Florida II, Inc. (CON

#10043) states that it established The Hospice Memorial Fund on October 1, 2001, a not-for-profit fund that distributes donations for community support and patient and family needs. Since some community and family needs are urgent in nature, the fund has a very fast turnaround time. Examples of services provided in the past include providing handicap accessible accommodations, transportation costs to visit a hospice patient and funds for local hospice and palliative serves and education. According to the applicant, total grants made from the fund totaled $1,164,590 between November 2007 and October 2008.

16 Compassionate Care Hospice Foundation Brochure and Newsletter are provided at Tab 8, CON Application #10042.


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3. Statutory Review Criteria

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

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

Need for an additional hospice program is evidenced by the availability, accessibility and extent to utilization of existing health care facilities and health services in this service area. The co-batched applicants are responding to published need of one hospice program in Hospice Service Area 11.

The following chart illustrates the increase in hospice admissions for the past five years. As shown below, admissions have increased from 7,005 in year ending June 30, 2003 to 8,310 in year ending June 30, 2008.

Hospice Admissions for Service Area 11 Fiscal Years 2003 - 2008

Fiscal Year Admissions

07/07 – 06/08 07/06 – 06/07 07/05 – 06/06 07/04 – 06/05 07/03 – 06/04 07/02 – 06/03

8,310 7,985 7,604 7,704 7,687 7,005

Source: Agency for Health Care Administration Florida Need Projections for Hospice Programs, 2003-2008.

Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) proposes to serve Service Area 11 by establishing an office in each of the three Miami-Dade County sub-areas upon initiation of operations: north Miami, central Miami, and Homestead. The applicant also intends to open an office in Marathon in order to better serve the residents of the Florida Keys. Compassionate Care Hospice states its development plan reflects both its intent to assure full service to all parts of the service area and its determination to tailor its program of services to the specific characteristics and needs of the residents within each of the identified areas. Care team staff members will be assigned to each office location. While direct care is provided in the home, offices and a physical location, the applicant states its multi-location approach to service will improve community visibility and outreach, provide a convenient place for family, counseling, and group support activities, and afford space for interdisciplinary care team meetings.


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Compassionate Care Hospice states that it currently offers hospice services in 12 different states through 29 office locations and these markets include communities with extremely diverse ethnic backgrounds and/or low per capita income. In servicing these communities, Compassionate Care states it has developed the experience and expertise needed to redress any hospice access issues which might exist within Service Area 11.

HCR Manor Care Services of Florida II, Inc. (CON #10043) states that the proposed project will enhance the availability, quality of care, efficiency, and accessibility of hospice services within Service Area 11. The applicant asserts that hospice services should be promoted to such a degree that the average person is aware of hospice service and has access to them when needed. Targeted efforts will be implemented for other special needs populations to ensure that they are aware of the benefits of hospice care and have ready access. In particular, Hispanics, HIV/AIDS patients and Alzheimer’s patients will be sought out with special outreach efforts. By establishing a hospice program in the area, Heartland will be able to work with families of appropriate long-term patients in nursing centers and ALFs to help them better understand the value of hospice care versus curative care, thereby improving availability and access. Heartland states its primary focus is on the continuous improvement of organizational performance. Essential activities include the design, measurement, assessment, and improvement of systems and processes to increase value and positively impact patient/family outcomes. The Heartland parent corporation is also a member of the National Hospice and Palliative Care Organization and adheres to its quality standards, as will Heartland Hospice. The applicant states it will also seek accreditation with this organization and will benefit from management consultation of the highest quality, access to a broad network of professional resources, and guidance critical to building intra and inter-organizational collaboration and strength. The applicant states it is not a stand alone provider but is supported by an established network of quality health care resources, both nationally and in the state of Florida. Relationships with area hospitals, physicians, discharge planners and others, along with local and regional Heartland Hospice staff, will assure that the hospice benefit will be maximized within the subdistrict, resulting in improved quality and better coordination of care throughout the continuum of health care services. The applicant asserts that it is committed to improving access for minority populations and transients within Service Area 11. The applicant also states that underserved groups such as Hispanics,


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HIV/AIDS patients and Alzheimer patients will receive special attention in its outreach efforts. The applicant also states that there is an opportunity to increase penetration rates in the subdistrict and that it is the appropriate applicant to lead this effort.

b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? Is the applicant a Gold Seal Program nursing facility that is proposing to add beds to an existing nursing home? ss. 408.035(1)(c), 408.035 (1)(j), Florida Statutes.

Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) states it is committed to providing the highest quality care possible to terminally ill patients and their families. Compassionate Care Hospice is a newly formed entity and as such does not have an operating licensure history in the State of Florida. The applicant states that through its relationship with its affiliate, Compassionate Care Hospice, which has a 15-year history of providing quality hospice care it has access to a substantial body of knowledge, skills and experience in establishing and operating high-quality hospice programs. Founded in 1993, the applicant states it is a community-based organization committed to providing the highest quality of hospice care to patients, their families and close friends in 12 states: New Jersey, Delaware, New York, Massachusetts, Georgia, Texas, South Dakota, Illinois, Missouri, Pennsylvania, Michigan and Minnesota. The applicant asserts that it is committed to providing the highest quality care possible to terminally ill patients and their families. The applicant states that examples of its standard of high quality care are demonstrated through its accreditation17, performance improvement plan18, compliance with data reporting, patient/family satisfaction surveys, staff membership in quality associations, staff continuing education, letters of support, and the standard of every hospice patient being seen in the home by the hospice’s medical director. HCR Manor Care Services of Florida II, Inc. (CON #10043) is a newly formed for-profit Florida corporation and as such does not have a licensure history. The ManorCare, Inc. affiliated hospice program in Service Area 4A, licensed on September 6, 2007 has no confirmed complaints as of February 3, 2009.

17 Initial Accreditation from CHAP is provided in Appendix 11, CON Application #10042. 18 A copy of the performance improvement plan is provided in Appendix 11, CON Application #10042.


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The applicant states that HCR ManorCare has invested heavily in training and research so its caregivers have the tools they need to provide high-quality care. For example, the applicant reports that HCR ManorCare has been part of a two-year collaborative effort studying pain management that was sponsored by the Centers for Medicare & Medicaid Services (CMS). Through the lessons learned in the pilot program, the applicant states there was an average improvement of approximately 40 percent in pain management across its skilled nursing centers as measured against the government’s quality measures for pain in 2004. The applicant states these results were achieved by adding to the care plan non-pharmacological interventions, including aromatherapy, hydrotherapy, exercise, music and massage. Heartland Home Health Care and Hospice programs are also accredited by the Community Health Accreditation Program, Inc. (CHAP), an independent, non-profit accrediting body, first established in 1965.

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. Compassionate Care Hospice of Miami Dade, Inc. (CON #10042): Compassionate Care Hospice of Florida, Inc. was formed as a for-profit corporation in Florida on October 20, 2008 for the purpose of operating a hospice in Florida with net assets of $0 and $70 in liabilities for the period ended November 30, 2008. At the date of the audit, no operating results were available. Without results from operations, an analysis of the short and long-term strength of the applicant cannot be made. Capital Requirements:

Schedule 2 indicates total capital projects of $805,928 which consist of the CON subject to this review, CON #10036 for a hospice in Subdistrict 6B, and $150,000 in other capitalization. Available Capital:

The applicant states that its parent corporation, Compassionate Care Hospice Group, Ltd. (Parent), will provide funding for the project through a line of credit provided by JPMorgan. In support of this statement, the Applicant provided a letter from JPMorgan showing a $2 million dollar line of credit and indicates that the entire line of credit is available. It should be noted that the applicant included operating results of its affiliate. Because, the affiliates operating results were not audited we did not consider them in this review.


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Staffing:

Schedule 6A indicates for year one ending December 31, 2010, the applicant forecasts 39.94 FTE’s as follows: administration 5.0 FTE’s, physicians 0.3 FTE, nursing 29.64 FTE’s, ancillary 1.0 FTE, dietary 0.5 FTE and social services 3.5 FTE’s. In the second year ending December 31, 2011, the applicant forecasts 74.40 FTE’s as follows: administration 7.0 FTE’s, physicians 0.6 FTE’s, nursing 59.80 FTE’s, ancillary 1.0 FTE, and dietary 0.5 FTE and social services 5.5 FTE’s. The applicant states it does not anticipate any problem with recruitment of the required staff. Compassionate Care asserts its effectiveness in recruiting high quality staff to meet its personnel needs, and has appropriate recruitment and retention policies, procedures, approaches and techniques in place that will be used to meet the staffing needs of the proposed program. Conclusion:

Funding for this project should be available as needed. HCR Manor Care Services of Florida II, Inc. (CON #10043): HCR Manor Care Services of Florida II, Inc. is a development stage company and a Florida for-profit corporation, incorporated in March 2008. As of April 30, 2008 the applicant had no assets and $350 in liabilities, with negative $350 in operating results.

The applicant provided audited financial statements of its ultimate Parent company, HCR Manor Care, Inc. (Parent), a for-profit corporation, for the periods ending December 21, 2007 and December 31, 2006. The December 21, 2007, year end is the result of the parent’s merger and conversion to a privately held company. These statements were analyzed for the purpose of evaluating the parent’s ability to provide the capital and operational funding necessary to implement the project. Short-Term Position: The Parent’s current ratio of 0.4 indicates current assets are less than half of the current obligations, a weak position. The working capital of negative $1 billion is in part a result of Manor Care, Inc. settling existing long-term debt as part of being purchased and held as a private company. Most of the purchase price consists of debt financing. The ratio of cash flow to current liabilities of 0.2 is well below average and weak position. Overall, the parent has a weak short-term position. (See table below).


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Long-Term Position: The ratio of long-term debt to net assets of 1.9 indicates the parent is highly leveraged and may have difficulty obtaining future debt as necessary. The most recent year had $16.9 million in operating income, which resulted in a 0.4 percent operating margin. Overall, the parent has a weak long-term position. (See table below). It should be noted that the parent was purchased and held as a private company. Based on information filed through the change of ownership process, the purchase was funded primarily with debt. The level of debt acquired by Manor Care is a significant increase and raises concerns about Manor Care’s long-term ability to service the debt. Capital Requirements: Schedule 2 shows the applicant has no capital projects or expenditures other than the two CON applications being filed to establish new hospice programs in Districts 7B and 11 will be financed by HCR ManorCare, Inc. The applicant is projecting a year one operating loss of $313,166. The applicant will have to fund the year one operating loss until profitability can be achieved. Available Capital:

Funding for this project will be provided by HCR ManorCare Inc. by way of cash on hand and internally generated and/or borrowed funds. ManorCare, Inc. reported cash flow from operations of $380.7 million and shows $57.9 million as cash on hand. It is unclear how much of the parents future cash flow will be needed to fund the debt acquired in the merger. Staffing:

Schedule 6A indicates for year one ending December 31, 2010, the applicant forecasts 27.61 FTE’s as follows: administrator 1.0 FTE, community educator 1.0 FTE, director of professional services 1.0 FTE, patient care coordinator 0.25 FTEs, chaplain 1.0 FTE, medical social worker 2.22 FTEs, office manager 2.0 FTEs, bereavement coordinator 1.0 FTE, medical director .05 FTE (contract), continuous care staff 4.20 FTEs, marketing/sales staff 1.5 FTEs, team coordinator 1.0 FTE, RNs 4.62 FTEs, HHA’s 4.62 FTEs, volunteer coordinator 1.0 FTE and dietician 0.05 FTE. In the second year ending December 31, 2011, the applicant forecasts 42.42 FTE’s which includes the addition of 14.81 FTEs to year one’s staff: patient care coordinator 0.75 FTE, chaplain 0.81 FTE, medical social worker 1.62 FTEs, office manager 1.0 FTE, bereavement coordinator 0.20 FTE, medical director (contract) 0.05 FTE, continuous care staff 3.06 FTEs, marketing/sales staff 0.50 FTE, RNs 3.36 FTEs, HHA’s 3.36 FTEs and dietician 0.10 FTE.


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

Based on the relatively small size of the project, funding for this project should be available as needed. However, the long-term financial position of the parent could have a negative impact on the applicant’s operations going forward.

ManorCare, Inc.

12/21/2007 12/31/2006

Current Assets (CA) $844,057,000 $619,194,000

Cash and Current Investment $57,921,000 $17,658,000

Assets Restricted for Capital Projects $0 $0

Non-Current Assets $1,694,345,000 $1,779,283,000

Total Assets (TA) $2,538,402,000 $2,398,477,000

Current Liabilities (CL) $1,908,665,000 $523,629,000

Total Liabilities $2,321,102,000 $1,825,284,000

Net Assets (NA) $217,300,000 $573,193,000

Total Revenues (TR) $3,770,458,000 $3,613,185,000

Interest Expense (IE) $32,218,000 $31,513,000

Operating Income (OI) $16,940,000 $291,221,000

Cash Flow from Operations (CFO) $380,688,000 $275,184,000

Working Capital ($1,064,608,000) $95,565,000

12/21/2007 12/31/2006

Current Ratio (CA/CL) 0.4 1.2

Cash Flow to Current Liabilities (CFO/CL) 0.2 0.5

Long-Term Debt to Net Assets (TL-CL/NA) 1.9 2.3

Times Interest Earned (OI+IE/IE) 1.5 10.2

Net Assets to Total Assets (NA/TA) 8.6% 23.9%

Operating Margin (OI/TR) 0.4% 8.1%

Return on Assets (OI/TA) 0.7% 12.1%

Operating Cash Flow to Assets (CFO/TA) 15.0% 11.5%


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d. What is the immediate and long-term financial feasibility of the

proposal? ss. 408.035 (1)(f), Florida Statutes.

Compassionate Care Hospice of Miami Dade, Inc. (CON #10042): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 89.0 percent, Medicaid at 3.4 percent, self-pay/uncompensated 2.3 percent and commercial insurance at 5.3 percent. The applicant indicated on Schedule 7 that the services it intends to provide are routine care, continuous care, inpatient care, and respite care for which the Department of Health and Human Services sets rates. The Federal rates were calculated for the Miami-Dade County, Florida Urban Areas Wage Index for Medicare Hospice payments of 1.0499 and inflated through December 2011. The average price adjustment factor used was three percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2008 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in the Table below. The applicant’s projected gross revenue was 1.1 percent or $102,364 greater than the calculated gross revenue. The difference is not considered material. Operating profits from this project are expected to increase from $208,897 for year one to a profit of $2,076,186 for year two. Conclusion:

This project appears to be financially feasible.


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HOSPICE REVENUE TABLE

CON #10042 Compassionate Care Hospice of Miami-Dade, Inc.

Wage Index for Miami-Dade County(1.0499)

Wage

Component Wage Index

Adjusted Wage Amount

Unadjusted Component

Payment Rate

Routine Home Care $96.17 1.0499 $100.97 $43.80 $144.77

Continuous Home Care $561.32 1.0499 $589.33 $255.62 $844.95

Inpatient Respite $78.37 1.0499 $82.28 $66.42 $148.70

General Inpatient $398.36 1.0499 $418.24 $224.10 $642.34

Payment Rate

Inflation Factor Year

Two

Inflation Adjusted Amount

Patient Days Year 2,

December 31-2011

Calculated Gross Revenue

Routine Home Care $144.77 1.067 $154.52 52,944 $8,180,872

Continuous Home Care $844.95 1.067 $901.86 850 $766,580

Inpatient Respite $148.70 1.067 $158.72 73 $11,586

General Inpatient $642.34 1.067 $685.60 709 $486,091

Total 54,576 $9,445,129

From Schedule 7 $9,547,493

Difference $102,364

Percentage difference 1.07%

HCR Manor Care Services of Florida II, Inc. (CON #10043): Schedule 7 of the application indicates that the services to be provided are routine home care, continuous care, inpatient respite and general inpatient. The payer types identified in the application as a percentage to total patient days are: Medicare at 90.0 percent, Medicaid at 6.9 percent, self pay/charity at 2.0 percent, and commercial insurance at 1.1 percent. The Department of Health and Human Services sets rates for routine home care, continuous home care, inpatient respite care, and general inpatient care. The Federal rates were calculated for Miami-Dade County, Florida wage index for Medicare Hospice payments of 1.0499 and inflated through June 2011. The average price adjustment factor used was three percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2008 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that


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number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in the Table below. The applicant offered 21 conditions to its proposed hospice program. Several of these conditions would likely have a financial impact on the applicant. Based on the notes accompanying the projections, it appears that the applicant has taken into consideration the costs associated with the proposed conditions in the financial projections. The applicant’s projected gross revenue was 8.2 percent or $502,287 less than the calculated gross revenue. Our analysis was based on gross revenues. The applicant does not show any contractual adjustments. Understating revenues is a conservative assumption and therefore, considered reasonable. The applicant projected an operating profit of $404,903 by the end the second year of operations. Conclusion:

This project appears to be financially feasible.

HOSPICE REVENUE TABLE

CON #10043 HCR ManorCare Services of Florida II, Inc.

Wage Index for Dade County(1.0499)

Wage

Component Wage Index

Adjusted Wage Amount

Unadjusted Component

Payment Rate

Routine Home Care $96.17 1.0499 $100.97 $43.80 $144.77

Continuous Home Care $561.32 1.0499 $589.33 $255.62 $844.95

Inpatient Respite $78.37 1.0499 $82.28 $66.42 $148.70

General Inpatient $398.56 1.0499 $418.45 $224.10 $642.55

Payment Rate

Inflation Factor Year

Two

Inflation Adjusted Amount

Patient Days Year 2, June 30-2011

Calculated Gross Revenue

Routine Home Care $144.77 1.067 $154.52 32,934 $5,088,940

Continuous Home Care $844.95 1.067 $901.86 899 $810,771

Inpatient Respite $148.70 1.067 $158.72 42 $6,666

General Inpatient $642.55 1.067 $685.82 1,085 $744,120

Total 34,960 $6,650,497

From Schedule 7 $6,148,210

Difference -$502,287

Percentage difference -8.17%


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e. Will the proposed project foster competition to promote quality and cost-effectiveness? ss. 408.035(1)(g), Florida Statutes.

Each co-batched applicant is offering a new choice of provider in the hospice service area.

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

With the large majority of patient care being provided from fixed-price government payer sources, a new hospice provider is not likely to have any discernable positive impact on competition to promote quality assurance or cost-effectiveness. However, with price not considered a major factor, competing hospice programs will likely focus on quality of service to remain competitive in the market. Therefore, although a new hospice provider is not likely to have any discernable positive impact on competition to promote cost-effectiveness, it is likely to have a positive impact on quality assurance. Compassionate Care Hospice of Miami Dade, Inc. (CON #10042): The applicant is projecting 5.3 percent of its patient days from managed care/commercial insured payers with 92.5 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid). HCR Manor Care Services of Florida II, Inc. (CON #10043): The applicant is projecting 1.1 percent of its patient days to come from managed care/commercial insured payers with 96.9 percent of patient days expected to come from fixed-price government payer sources (Medicare and Medicaid). As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed-priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Approval of either project is not likely to result in price-based competition.


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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 and Ch. 59A-3 or 59A-4, Florida Administrative Code.

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

g. Does the applicant have a history of providing health services to Medicaid patients and the medically indigent? Does the applicant propose to provide health services to Medicaid patients and the medically indigent? ss. 408.035(1)(i), Florida Statutes.

Medicaid paid 4.5 percent of total hospice patient days nation-wide in 2007 and 4.8 percent in 2006. In 2007, total hospice admissions/patients paid by Medicaid were 5.0 percent and 5.3 percent in 2006.19 In Florida, Medicaid paid 4.6 percent of CY 2007’s total patient days and 5.6 percent of CY 2006’s. During FY 07-08 Medicaid patients accounted for 5.0 percent of total Florida hospice admissions and 4.4 percent of hospice patient days. During FY 07-08, Florida hospices reported 4.3 percent of total admissions and 2.8 percent of total hospice patient days were uncompensated care.20 Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) states that Compassionate Care Hospice is both Medicare and Medicaid certified and has a history of providing health services to Medicaid patients and the medically indigent. According to the applicant, recent data shows that collectively Compassionate Care Hospice programs provided 17,377 Medicaid days representing five percent of total patient days and over seven percent of total patient days to self-pay/charity/other patients. The applicant does not provide the time period covered by this recent data. Schedule 7A shows 3.24 percent of total annual patient days for charity care/self-pay in year one, and 2.20 percent of total annual patient days for charity care/self-pay for year two. Compassionate Care’s patient day Medicaid percentage is projected to be 5.05 percent for year one and 3.37 percent for year two.

19 NHPCO Facts & Figures on Hospice Care released October 2008 from http://www.nhpco.org. 20 Florida specific information from A White Paper: Will Elimination of the Optional Medicaid Hospice Benefit Save the State of Florida Money? Prepared for: Florida Hospice & Palliative Care in December 2008. FY 07-08 data based on reports from 32 of 42 reporting Florida Hospices.


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HCR Manor Care Services of Florida II, Inc. (CON #10043) states that it and its parent company, HCR ManorCare, have a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. However, the applicant as a start-up company, does not have a history of service to any patients. In 2007, the applicant states Heartland hospice provided approximately $3.4 million in charity care to its hospice patients. The applicant provides the following as its projected payer mix for Heartland for the first two years of operations. Schedule 7A shows that self-pay and charity/other accounts for two percent of patient days while Medicaid accounts for 6.9 percent of total patient days for year one and two respectively.

F. SUMMARY

A fixed need pool was published for a new hospice program in Hospice Service Area 11, Miami-Dade and Monroe Counties. Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) proposes the establishment of a new hospice program in Hospice Service Area 11, Miami-Dade and Monroe Counties. The applicant is proposing total project costs of $363,469 with year one operating cost of $3,437,118 and year two costs of $7,021,424. Compassionate Care proposes eight general and nine specific conditions. Briefly stated the specific conditions include: a commitment to open four office locations, reduce severe pain within 48-hours, become CHAP accredited, adopt specific standards and qualifications for staff, provide at least 1.5 percent of total annual patient days as continuous care days, contact patients daily, dedicate one FTE for a bilingual marketing coordinator, assure medical directors access every patient upon admission, and provide hospice services to terminally ill inmates. See pages 3-7 for in-depth description of the applicant’s proposed conditions. HCR Manor Care Services of Florida II, Inc. (CON #10043) proposes the establishment of a new hospice program in Hospice Service Area 11, Miami-Dade and Monroe Counties. The proposed total project cost is $471,825 with year one operating costs of $4,528,026 and year two costs of $7,302,823.


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Heartland Hospice proposes 21 conditions which briefly stated include the following: establish a primary office in Homestead or surrounding area, develop programs focused on improving access, employ bilingual staff, provide specialized Alzheimer’s training, address needs of HIV/AIDS patients, seek accreditation with National Institute for Jewish Hospice, include Hispanic community representatives on the Community Advisory Board, develop vigil volunteer program, obtain CHAP accreditation, develop home health services, provide educational seminars, establish a patient/family special needs fund, budget $15,000 for special wish fund, provide $10,000 annually in tuition reimbursement for employees, contract for one specialized palliative care physician FTE, conduct semi-annual meeting with contracted hospitals and long-term care facilities, implement a public education program, provide 24-hour, seven days a week telephone response by staff, implement volunteer program, develop a children’s and family retreat program and reduce pain to targeted goals within the first 48 hours of admission. See pages 7-11 for in-depth description of the applicant’s proposed conditions. Need/Access:

Each applicant is responding to published need for a new hospice program. Each applicant states that there is unmet need in Miami-Dade and Monroe Counties, which ranged from access issues for minority populations including Hispanics and African-Americans, chronically ill patient populations with Alzheimer’s disease and HIV/AIDS, to the growing elderly inmate population. Both co-batched applicants provided evidence that they have local support for their proposals to enter the service area. However, Heartland submitted nine times the letters of support submitted by Compassionate Care Hospice. Over a third of Heartland’s letters of support were from influential figures and business owners within the Hispanic community. Local letters of support essentially state that they look forward to working with the applicant should the applicant be awarded a CON. Compassionate Care Hospice includes letters from Fishermen’s Hospital, Larkin Community Hospital, Lower Keys Medical Center, the Borinquen Health Care Center, Inc, and Victoria Nursing and Rehabilitation Center that indicate a willingness to contract for inpatient care. Heartland also has letters of support from Heartland Healthcare Center of Miami Lakes and Heartland Healthcare Center of Kendall that indicate a willingness to contract for inpatient care. Both facilities are HCR ManorCare affiliates and further demonstrate Heartland’s commitment to continuity of care in the service area.


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Both applicants have agreed to measurable conditions, if awarded the CON, to ensure that its proposed program offers improved access to hospice care, improved education regarding available hospice services, and to address any cultural barriers to hospice care in Miami-Dade and Monroe Counties. Neither applicant agreed to condition the CON upon providing a minimum of patient days per year to charity patients. Recent changes in hospice licensing law indicate that hospice programs that fail to meet their CON condition without good cause could lose their license. The Agency’s need methodology that resulted in published need for a new program in Miami-Dade and Monroe Counties showed the projected number of admissions minus the current number of admissions for the January 2010 planning horizon as 3,546. Compassionate Care proposed the largest program to address this published need:

Total Projected Admissions By Applicant for Years One and Two

CON # Applicant Year One Year Two Both Years

10042 Compassionate Care 374 708 1,082

10043 HCR ManorCare 321 437 758 Source: CON Application #’s 10042 and 10043.

Quality of Care:

Each applicant offered evidence of its ability to provide quality care. Financial Feasibility/Availability of Funds: Compassionate Care Hospice of Miami Dade, Inc. (CON #10042): Funding for the project should be available and the project appears to be financially feasible although the short and long-term financial position could not be determined based on the financial statements provided by the applicant. HCR Manor Care Services of Florida II, Inc. (CON #10043): Based on the relatively small size of the project, funding for this project should be available as needed. However, the long-term financial position of the parent could have a negative impact on the Applicant’s operations going forward. Medicaid/Charity Care:

Medicaid paid 4.5 percent of total hospice patient days nation-wide in 2007 and 4.8 percent in 2006. In 2007, total hospice admissions paid by Medicaid were 5.0 percent and 5.3 percent in 2006. In Florida, Medicaid


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paid 4.6 percent of CY 2007’s total patient days and 5.6 percent of CY 2006’s. During FY 07-08 Medicaid patients accounted for 5.0 percent of total Florida hospice admissions and 4.4 percent of hospice patient days. During FY 07-08, Florida hospices reported 4.3 percent of total admissions and 2.8 percent of total hospice patient days were uncompensated care. Compassionate Care Hospice of Miami Dade, Inc. (CON #10042) applicant states that it has a history of providing health services to Medicaid patients and the medically indigent. Schedule 7A shows 3.24 percent of total annual patient days for charity care/self-pay in year one, and 2.2 percent of total annual patient days for charity care/self-pay for year two. Compassionate Care’s patient day Medicaid percentage is projected to be 5.05 percent for year one and 3.37percent for year two.

HCR Manor Care Hospice of Florida, Inc. (CON #10043) and its parent company, Manor Care, state they have a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. Schedule 7A shows that self-pay and charity/other accounts for two percent of patient days while Medicaid accounts for 6.9 percent of total patient days for years one and two respectively.

G. RECOMMENDATION

Approve CON #10043 to establish a new hospice program in Hospice Service 11, Miami-Dade and Monroe Counties. The proposed total project cost is $471,825 with year one operating costs of $4,528,025 and year two costs of 7,302,823. CONDITIONS: 1. Heartland Hospice commits to establish a primary office location

for District 11 in Homestead or the surrounding area in southern Dade County.

2. Heartland Hospice commits to the development and

implementation of programs focused on improving access to hospice services by Hispanics (and the subgroups within) and persons of Jewish heritage in Service Area 11. The program will include training on cultural differences and competencies and flexible programming to meet their unique needs. Special community education efforts, clinical care protocols, and bereavement services for families will be implemented to increase


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participation in hospice for groups traditionally underrepresented. Programs for other cultural groups will be developed as the needs are identified in the community. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition was met.

3. Heartland Hospice commits to employ bilingual, Spanish-speaking

staff and to provide translated forms and literature. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

4. Heartland Hospice commits to provide specialized training for staff

working with individuals with Alzheimer’s disease to enhance the provision of hospice care to such individuals. Compliance with this condition will be documented by annually providing the Agency with a list of training dates to document that the training has taken place.

5. Heartland Hospice commits to address the specific needs of

patients who have HIV/AIDS and include information in clinical training programs to meet this identified community need. Staff will receive specialized training to enhance the hospice care provided to such individuals. Compliance with this condition will be documented by annually providing the Agency with a list of training dates to document that the training has taken place.

6. Heartland Hospice commits to seek initial accreditation with the

National Institute for Jewish Hospice within two years of opening to better serve Jewish residents of Miami-Dade and Monroe Counties. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

7. Heartland Hospice commits to include representatives from the

Hispanic community on its Community Advisory Board in Service Area 11. The Community Advisory Board will be a volunteer advisory group created to more fully address community issues and will inform Heartland of issues regarding hospice and end-of-life care viewed from the prospective of area residents and businesses (especially within Hispanic and Jewish communities), conduct information sessions as deemed appropriate for the purposes of soliciting further community planned programs and services to address service gaps and access issues. Compliance with this condition will be documented by annual submission of a


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declaratory statement to the Agency that the condition has been met.

8. Heartland Hospice commits to develop a Vigil Volunteer program in

Service Area 11, to ensure that patients do not die alone. Vigil volunteers are also available to give support to family members who need a break from the bedside of their loved ones during the dying process. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

9. Heartland Hospice commits to apply for accreditation by the

Community Health Accreditation Program within the first year of opening the proposed office in Service Area 11. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency that the condition has been met.

10. HCR ManorCare, the parent company of the applicant, commits to

develop home health services in Service area 11 in conjunction with the approval of this hospice application. Compliance with this condition is documented by the letter in Appendix 4 stating HCR ManorCare’s intent to develop home health services in District 11.

11. Heartland Hospice commits to providing a minimum of one

educational seminar per quarter focusing on end-of-life issues for professionals who work with end-of-life patients (such as physicians, nurses, religious leaders, etc.). Heartland hospice will commit a minimum of $75,000 over the first two years of operation for this effort. In addition, the applicant will provide a listing of educational materials regarding end-of-life issues at these seminars. Compliance with this condition will be documented by annually providing to the Agency a list of seminars conducted and the dates the seminars were offered.

12. Heartland Hospice commits to establish a patient/family “Special

Needs Fund” of $10,000 for each of the first five years of operation of the Service Area 11 to be used by the clinical team members to meet unusual and uncovered patient and family needs. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

13. Heartland Hospice commits that for at least the first five years of

operation in Service Area 11, to a minimum annual budget of $15,000 per year for the provision of a special wish fund for


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hospice patients and families in Service Area 11. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency by the hospice director.

14. Heartland Hospice commits to provide up to $10,000 annually for

tuition reimbursement for employees to continue education in hospice or end-of-life care. This includes tuition reimbursement for Heartland Hospice staff to obtain certified hospice palliative nurse certification, further enhancing the quality of care for hospice residents, as well as supporting staff availability to advance professionally. There will also be an emphasis on promoting tuition reimbursement for the advancement of Hispanic staff. Compliance with this condition will be documented by an annual affirmative statement to the Agency that a tuition reimbursement process is in place.

15. Heartland Hospice commits to contract for 1.0 FTE physician

specializing in palliative care in addition to the medical director, to offer palliative care consults for patients served by Heartland Hospice as well as to hospitals, nursing homes, and other care settings in the community in the fiscal year following Heartland Hospice reaching an average daily census of at least 100 patients. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

16. Heartland Hospice commits to conduct semi-annual meetings with

all contracted hospitals and long-term care facilities to review quality of service and responsiveness. Heartland Hospice will establish a written policy in Service Area 11 to this effect. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

17. Heartland Hospice commits to create and implement a public

education program about the benefits of hospice care in Miami-Dade and Monroe Counties. This program will be similar to the program recently implemented by Heartland Hospice in Jacksonville. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.

18. Heartland Hospice commits to provide 24-hour, seven days a week,

telephone response provided directly by Heartland staff. HH also commits to provide 24-hour, seven days a week interpretive services, either by Heartland staff or through a contracted interpretive. Compliance with this condition will be documented by annual submission of a declaratory statement to the Agency.


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19. Heartland Hospice commits to implement a volunteer program

within the first two years of operation that focuses on groups who traditionally have not been significantly involved in hospice programs such as teens and ethnic and racial minorities. Compliance with this condition will be documented by the annual provision of a records summary to the Agency based on the records kept routinely by the Heartland Hospice volunteer coordinator.

20. Heartland Hospice commits to develop, in year two, a children’s

and family retreat program(s) to serve the residents of Service Area 11. These programs will augment traditional bereavement services especially for children experiencing grief and loss. Compliance with this condition will be documented by an affirmative statement that this program has been developed and the provision of program description to the Agency.

21. Heartland Hospice commits that a pain assessment will be

completed on all patients at time of admission, as part of an ongoing pain management program focused on reducing pain to targeted goals within the first 48 hours of admission. Heartland Hospice will implement existing corporate policies related to pain management as included in Appendix 5. This condition will be documented by annual submission of a declaratory statement that the condition has been met.

Deny CON #10042.


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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration

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

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

Jeffrey N. Gregg

Chief, Bureau of Health Facility Regulation

state agency action report on application for certificate ... · state agency action report on...

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