state agency action report - the agency for...

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Compassionate Care Hospice of Lake and Sumter, Inc./CON #10140

200 Lanidex Plaza, Suite 2101

Parsippany, New Jersey 07054

Authorized Representative: Judith Grey

(973) 402-4712

Harbor Light Hospice of Florida, Inc./CON #10141

800 Roosevelt Road #C206

Glen Ellyn, Illinois 60137

Authorized Representative: Freeman Smith

(630) 942-0100

Hospice of Marion County, Inc./CON #10142

3231 SW 34th Avenue

Ocala, Florida 34474

Authorized Representative: Mary Ellen Poe

(352) 873-7434

VITAS Healthcare Corporation of Florida/CON #10144

100 South Biscayne Boulevard, Suite 1300

Miami, Florida 33131

Authorized Representative: Dr. Ronald T. Luke

(512) 371-8166

2. Service Area/Subdistrict

Hospice Service Area 3E, Lake and Sumter Counties

CON Action Numbers: 10140, 10141, 10142 and 10144

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B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to

establish a hospice program in Hospice Service Area 3E. However, letters

of support were submitted, as discussed below.

General Letters of Support

Sue Cordova, President and CEO of the United Way of Lake & Sumter

Counties, Inc. submitted an email which states that while (her

organization) does, “not have a specific Hospice Care organization to

support, we do encourage you to give preference to a non-profit Hospice.”

She cites that the majority of individuals in the service area live below

the poverty level and that, “a non-profit provider is better equipped to

handle our population and become a partner to other service providers

that can assist during a time of crisis.”

Compassionate Care Hospice of Lake and Sumter, Inc. (CON #10140)

had 25 letters of support from Hospice Service Area 3E dated from May

10, 2012 - June 15, 2012. They included cardiologists, other physicians,

a long-term care hospital, a nursing home, three assisted living facilities,

two home health agencies, a Florida State Senator and a veteran’s

organization. In general, these letters maintained the need for a hospice

choice in the service area as well as advocating for Compassionate Care

based upon its reputation for quality services.

State Senator D. Alan Hays of the 20th District emphasizes “the need for

patient choice and enhancement of hospice services in the

community…competitive environments lead to quality enhancement and

improvements as opposed to the potential for complacency.” Senator

Hays goes on to say, “Compassionate Care is known for providing quality

services in the communities in which it operates. It also matches its

unique abilities to the local and needs of the communities in which it

serves.”

Eight cardiologists submitted letters of support. Six of these letters

stated the community’s need for Compassionate Care’s Cardiac

Connections program, with three cardiologists citing that 20-30 of their

patients “are neither candidates for surgery or transplant…and as such

their only option at this time is admission to the hospital when they

become symptomatic.” These cardiologists include Dr. Prabhakara B.

Kunamneni, Central Florida Cardiology & Vascular Center, LLC; Dr.

Ronnie Sabbah, Florida Heart and Vascular Center; Dr. Patrick K.


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Williams, Florida Heart and Vascular Center; Dr. John R. Hurt, Florida

Heart and Vascular Center; Dr. Osama Al Suleiman, Heart and Vascular;

Dr. Jose R. Rosado, Florida Heart and Vascular Center; Dr. Steven J.

Nerad; Dr. Thomas F. Perente, Heart Care & Vascular Medicine. Seven

additional physicians sent in letters of support including: Dr. Robert

Meade, Florida Heart and Vascular Center; Dr. Jose Carrau, South Lake

Neurology; Dr. Cheryl Durstein-Decker, the Doc’s IN; Dr. Annil Chet

Sawh, Orlando Medical Group; Dr. Mary Rose Boehm; Dr. Khalid

Maqsood, South Lake Gastroenterology; Dr. Rajab Abu Khadrah, South

Lake Gastroenterology. The office manager of White House Medical

Center, a physician’s office in Clermont, also submitted a letter of

support.

Other letter writers include Commander Johnny Gibbons of the

American Legion Veterans Memorial Post 347, Karen Blakely,

Administrator of Ruleme Center, a 138-bed Lake County SNF and

Steven M. Klein, CEO of Promise Hospital of Florida at the Villages.1

Three assisted living facilities submitted letters, including: Jim

Jennings, Executive Director of Superior Residences of Clermont; Gerard

Zamanski, Administrator of Leisure Manor Assisted Living Facility;

Debbie Flaherty, Executive Director of Sterling House, Brookdale Senior

Living.2 The two home health agency letters were from representatives of

Phoenix Home Care and Angels Care Home Health. Promise Hospital of

Florida at the Villages and Superior Residences of Clermont stated their

intent “to enter into appropriate arrangements to incorporate

Compassionate Care into our resident choices for hospice care.”

Harbor Light Hospice of Florida, Inc. (CON #10141) had 53 letters and

one memo of support for its services. Six letters and the memo are from

Hospice Service Area 3E. Two letters are from Steven W. Sell

representing Osprey Point Nursing Center, a 60-bed SNF located in

Sumter County. One letter states, “Nursing home facilities are required

to offer choice in physicians, food and every aspect of care, yet, there is

only one hospice provider in our county.” Mr. Sell’s second letter

indicates that Osprey Point would be “interested in and agreeable to

developing a contract with Harbor Light Hospice for the provision of

inpatient hospice services.”

Three assisted living facilities submitted letters of support, Waterman

Cove, TLC Family Care Home and Mission Oaks. Two home health

agencies provided letters. Christine Magnifico, Vice President of

Advanced Nursing Concepts, Inc. stated “I feel it crucial to provide a

1 Mr. Klein also sent a letter of support for VITAS Healthcare Corporation of America. 2 Ms. Flaherty also sent a letter of support for Hospice of Marion County.


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choice when presenting any type of medical care.” Ben Miccichi,

Administrative Officer of Maxim Healthcare Services, sent in a letter and

a memo of support for the proposed program.

The remaining 47 letters of recommendation/reference are from out of

state from providers working with current Harbor Light Hospice

locations. Thirty-seven of these letters are not dated; the remaining eight

letters are dated June 6, 2012-June 18, 2012. These letters include one

doctor, two long-term care hospitals and 43 from nursing

homes/assisted living facilities. The letters speak of the organization’s

service, knowledge and dedication. Several facilities maintain that even

though this is a small organization, Harbor Light adapts quickly and

tailors programs to fit resident’s needs.

Hospice of Marion County, Inc. (CON #10142) had 231 letters of

support and one email for its project, 146 are from or serve residents

within Hospice Service Area 3E. Three of these letters were unsigned.

Forty-one of these letters were not dated, 190 were dated February 24,

2012 through June 14, 2012. These include three members of the

Marion County government, six members of the Marion County Chamber

of Commerce Hispanic Business Council, a representative of a college, 23

members of religious organizations, one outpatient clinic, 57 physicians,

10 service organizations, two physical therapists, 19 assisted living or

skilled nursing facilities, 14 care management/home care service

providers, 30 residents from Lake/Sumter County, 27 residents from

outside the service area (the majority from Marion County), 11 health

care facilities/medical practices, 15 businesses, 10 family members of

patients and two volunteers.

Letters from physicians serving residents within Hospice Service Area 3E

include: Four members of the Ocala Neurosurgical Center; one member

of the Villages Lung & Sleep Ctr.; Dr. William Rodriguez, Dr. Anish K.

Khanna, Dr. Asm Rahman, Dr. Darin S. Brown, Dr. Syed Umair,

Dr. Abminav Khanna, Dr. David Stephenson and one other doctor from

the Ocala Hospitalist Group; Dr. Srinivas Reddy; Dr. Clarissa R.

Abrantes, Institute of Medical Excellence; Dr. Sandeep K. Thaper,

Central Florida Hematology and Oncology; Dr. Fariborz Delbakhsh;

Dr. Michele Hornstein, Central Florida Medical Care; Dr. Sheri Hamnik,

Neurology Center of Excellence; Dr. Uzoma Nwaubani, Female

Continence & Pelvic Surgery Center; Dr. Tuan K.I. Dean, Villa Medical

Group; Dr. Larry Foster, Leesburg Family Medicine; Dr. Jay Shaktawat,

Health First Internal Medicine Associates; Dr. Sundeep Shah, Dr. Eldar

Baigabatov, Dr. James S. Miller and Dr. Hazem El-Arousy of Premier

Medical Associates; Dr. Stephanie Walker, Rivers Family Medicine;

Dr. Frederick M. Yutani, Solanki Cardiology, LLC; Dr. Joyce Smolarski,


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Southeastern Integrated Medical; Dr. Winston E. Evalle; Dr. Donald T.

Eagle, Florida Physicians Medical Group; Dr. Pedro J. Arroyo; Dr. Kevin

Brown, New Beginning, TCM; Dr. Stacy John Berckes, Florida Pain

Management Center, Inc.; Dr. Sergio Balingit; Dr. Ravi P. Gupta and

Dr. Norman Novis of Mid-Florida Primary Care; Dr. Abu Azizullah,

Internal Medicine Practices; Dr. Catherine B. Horner of Family Doctors of

Belleview; Dr. Stanimir Stantchev, Florida Medical Associates; Dr. Robert

Boissoneault, Oncology Institute; Dr. Khai Chang, Dr. Shahbaz Cheema,

Dr. Page Smith and Dr. Ma Thuzar Aung of Lakeview Internal Medicine,

P.A.; Dr. Rakesh Rohatgi, Tri-County Hematology & Oncology;

Dr. Lourdes M. Mathew, Lake Cancer Medical Center; Dr. Thomas

Cartwright of Ocala Oncology.

Ten representatives of health care organizations/medical groups that

support the service area sent in letters of support, including: Carolyn

Porter, Director of Case Management and Dr. Lon H. McPherson, Senior

Vice President of Medical Affairs/Chief Quality Officer at Munroe

Regional Medical Center; Dr. Anette V. Nieves of Munroe Regional

Medical Center’s clinic, The Oaks at 138th; Raymond J. McNeal, Practice

Administrator and Nancy Spano, Clinical Services Supervisor of Ocala

Oncology; Timothy I. Sullivan, member of the Board of Directors at

Central Florida Health Alliance; Dolly McCranie, Director of Case

Management at Central Florida Health Alliance and at The Villages

Health System; Steven Marc Capps of Thomas E. Langley Medical Center;

and Maen Hussein of Florida Cancer Specialists. Kenneth R. Mattison,

President and CEO of Florida Hospital Waterman stated Waterman is

willing to consider contracting with Hospice of Marion County (HMC) to

provide short-term inpatient care.

Dr. K. Todd Donahoe of the Department of Veterans Affairs, The Villages

Outpatient Clinic, sent in a letter of support. Two physical therapists

voiced their support—Cindy Mill, Clinic Manager of Fit for Life Physical

Therapy and Ed Yuiska, Rehab Golf Specialist at Lake Centre for Rehab.

Ten assisted living facilities/skilled nursing facilities that support the

service area sent in letters of support, including: Pat Manco,

Administrator at The Bridgewater at Waterman Village; Dori Beard,

Executive Director and Allison Metcalf, Marketing Director at Mission

Oaks Assisted Living and Memory Care; Lois Pattison of The Springs of

Lady Lake; Vincent A Zaun, Nursing Home Administrator of Lady Lake

Specialty Care;3 Debbie Flaherty, Executive Director of Sterling House; a

representative of Savannah Manor; Diana Saxton of Lexington Park; Bill

Reyes, Caregiver at Pleasantvillle Assisted Living Facility; Bonnie Varnell

at Lake Ridge Village.

3 Mr. Zaun also sent in a letter of support for VITAS Healthcare Corporation of Florida.


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Twenty-two members of the religious community that serve the hospice

service area were represented, including: Ronald W. Mansdoerfer; the

Very Reverend John C. Giel, Pastor at the Catholic Community of St.

Paul; Billy Ray, Pastor of Evangelism, FBC Bushnell; an assistant pastor

at Celebration of Praise Church; Dr. M. McCoy Gibbs, Minister of

Visitation at Morrison United Methodist Church; Eitan Zur, President of

Temple Shalom; Father Peter Sagorski, Pastor of St. Vincent de Paul

Catholic Church; Deborah West, Administrative Assistant of Union

Congregational Church; Bruce W. Stewart, Senior Pastor at Open Door

Baptist Church; Reverend Pedro Zapata, Pastor of St. Lawrence Catholic

Church; Father Hugh Bromiley, Rector at St. George Episcopal Church;

Reverend Jeffrey Thomas, First United Methodist Church; Michael

Wayne Hood, Pastor of Bushnell Presbyterian Church; Deborah Marsich

the Faith Community Nurse Coordinator, Judith Woletz a Faith

Community Nurse and Joy Nutter at Hope Lutheran Church; Dr. Chris

Hardeman, Pastor at Faith Presbyterian Church; 14 members of the

United Church of Christ at The Villages; Richard Fountain, Pastor at

First Baptist Church; William A. Kamp, Pastor at First Presbyterian

Church of Wildwood; Donald H. Garms Sr., Pastor at Lighthouse Worship

Center Church of God; Andrea Cauthen, Children’s Pastor at First United

Methodist Church; a representative of Providence Baptist Church. Two

representatives of organizations within the service area sent in letters of

support—the Vice Chair of the Early Learning Coalition and Nick Jones,

President of The Village Airheads (COPD support group).

Seven care management/home care/home health agencies that serve

Subdistrict 3E support the proposed program, including: Beulah Scott,

Owner and President of All Coast Home Health Services; Summer Minor,

Administrative Assistant at Preferred Home Health; Deborah Stiles,

Assistant Director at McCoy Adult Day Care Center; Jan Marino, Account

Manager at infinity Homecare; Don Johnson at Heidi’s Haven; Robbi D.

Funderburk, Patient Care Coordinator at Greystone Home Healthcare;

Jamie Reardon, Director of Operations at Amedisys Home Health Care;

Rhonda L Combs, Administrator at Daycare HomeCare; Connie Michalik,

Administrator at Waterman Village Home Care; the Director of Health

and Wellness at Lake Harris Health Systems, LLC. Ten representatives

of business that serve Subdistrict 3E sent in letters of support,

including: Sheila Endicott, Manager of All Faiths Cremation Society;

Patricia De Roe, Manager of The Lost Parrot; Bob Bachelor, owner of The

Paint Shoppe; Amy Reed Pittman, Attorney at the Millhorn Law Firm;

Rodney J. Len, General Manager at Danny Len Buick-Pontiac & GMC

Trucks; Greg A. Beliveau, President of LPG Urban & Regional Planners,

Inc.; Annette Varner and Patty Schiefer at CenturyLink; Amanda

Wettstein at That Company; Judy Owens at Cupcake Delights.


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In general these letters stated that Hospice of Marion County provides

excellent care and service, is dedicated to ensuring the well-being of

patients/families/friends during enrollment to the program and is a

leader in providing end-of-life education to the general community as

well as health care professionals. The remaining 85 out-of-the-service-

area letters reiterate the above as well as speaking to the Hospice of

Marion County’s reputation within Marion County as an involved

member of the community.

VITAS Healthcare Corporation of Florida (CON #10144) had 59 letters

of support, 29 are from Hospice Service Area 3E or serve residents within

Hospice Service Area 3E. Two of these letters are not dated. The

remaining letters are dated May 8, 2012-June 18, 2012. These include

representatives from three hospitals, a county official, three case

managers, three physicians, four members of the religious community,

four representatives of organizations, one higher education director, five

skilled nursing homes/assisted living facilities, two residents and three

care management/home care service providers.

Letters from or serving residents from Hospice Service Area 3E were

received from: Fred Harrop, USAF, Manager of Veteran Services at the

Sumter County Board of County Commissioners; Faye Rose, Director of

Pastoral Care, Florida Hospital Waterman; Steven M. Klein, CEO of

Promise Hospital of Florida at the Villages; Sita Price, Coordinator of the

Heart Failure Program at ORMC Orlando Health Heart Institute;

Kimberly Hogan, Director of Case Management at Health Central

Hospital; Courtney Lemming, Case Manager for the Cardiovascular ICU

at Health Central Hospital; Tara L. Curry, Case Manager at Health

Central Hospital; Dr. Kerlan Peter Wolsley, South Lake Hospital

Intensivist; Dr. Charles Morgan; Dr. Jeffrey Cohen, Nephrology

Associates of Central Florida; Reverend John W. Harrington, Senior

Pastor at Morrison United Methodist Church; Reverend Annette Stiles

Pendergrass, North Central District Superintendent of the United

Methodist Church; Timothy Whitaker, Resident Bishop of the United

Methodist Church; Reverend Todd Bardin, Montverde United Methodist

Church; Sharon Melton, Director of Programs for the Alzheimer’s

Association of Central and North Florida Chapter; Candace Huber of

Transformation Communities; April Carpenter, Campaign Manager for

the Leukemia & Lymphoma Society of Northern & Central Florida

Chapter Light the Night; Bonnie Cruz, President of the Florida

Association Directors of Nursing Administration, LTC; Margaret S.

Wacker, Director of the Nursing Program at Lake Sumter Community

College; Vincent A. Zaun at Lady Lake Specialty Care Center; Teresa

Mena, Director of Nursing at The Edgewater at Waterman Village; Dana


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Weaver, Administrator of Sutton Homes; Kelley Keoppen, owner and

Administrator at The Gardens at Lakeview; Terry Haehnel, Executive

Director at Emeritus at Oak Park; Robert Lowe, President and owner of

BrightStar of Lake County; Deborah Snow, Community Liaison at

Phoenix Home Care; John Lazo, Area Director of CSI—Caregiver Services,

Inc. These letters speak to VITAS’ experience, quality and ability to

provide services and education to Lake and Sumter County residents.

Many mentioned VITAS’s commitment to charity care patients. Of

particular note, two letters mentioned the current limited resources for

hospice in Lake County. Sita Price of ORMC’s Orlando Health Heart

Institute mentions that, “The one provider in Lake County has not been

able to manage the needs of my advanced heart failure patients.”

Dr. Jeffrey Cohen states, “Since there is only one hospice provider in

Lake County, I have had to redirect patients to Orange County in-patient

units as VITAS is willing to care for these more complicated patients.”

Two of the nursing homes, Lady Lake Specialty Care Center and The

Edgewater at Waterman Village, stated that they would consider

contractual arrangements with VITAS upon approval.

The remaining 30 letters are from out of the service area but within the

State of Florida—these letters attest to VITAS’ success in other parts of

the state. A relatively common theme is that VITAS is supportive to

patients and families, provides outreach and educational tools as well as

highly professional. Several letters speak of VITAS’ commitment to the

community through several financial contributions and participating in

charitable events. Many letters mentioned VITAS’ commitment and

willingness to care for charity care patients.

In addition to the above letters, the applicant also included a letter from

R. Terry Rigsby, Attorney at Law, with Pennington, Moore, Wilkinson,

Bell & Dunbar. Mr. Rigsby cites an orchestrated letter-writing campaign

by the existing hospice in Service Area 3E, Cornerstone Hospice &

Palliative Care, “to convince the Agency that in spite of the unchallenged

published need, no additional hospice should be approved to serve Lake

and Sumter Counties.” Mr. Rigsby responds to this campaign by stating,

“Choice and regulated competition in the provision of hospice care are in

the public’s best interest. The Agency’s hospice need projection should

outweigh the desires of an existing provider that seeks to maintain its

monopoly, as there is no demonstrated reason not to approve an

additional program for the 3E service area.”


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Letters of Opposition

Mr. Karl David Acuff wrote on behalf of Cornerstone Hospice, Inc., the

existing provider in Hospice Service Area 3E, stating that it accepts that

the fixed need methodology projects a need for one new program in this

batch cycle. However, Cornerstone does object to the trend of applicants

arguing that a second hospice could be approved in addition to an

approval under the fixed need pool. Mr. Acuff states, “Hospice Service

Area 3E is one of the least populous service area and would not benefit

from the addition of multiple providers, the confusion amongst the public

and splintering of health care resources, including personnel, would

diminish the cohesiveness, continuity and potentially even the quality of

hospice care in the community. Mr. Acuff’s letter included 37

unduplicated letters of opposition, described below.

Seven of these letters were not dated; the remaining 30 were dated

June 4, 2012 through June 19, 2012. The letters cited Cornerstone

Hospice’s high quality care, knowledge and experience to the residents of

Lake and Sumter Counties. The majority of these letters stated that they

did “not see an unmet need for hospice services in our local community.”

These letters arrived from a variety of sources. One pastor, the Reverend

Ed Waters of St. Timothy Catholic Church submitted a letter. Four

health care administrators sent in letters: Rebecca Grohler, Manager of

Operations at InterCommunity Cancer Centers; Debra Trovato,

Administrator of Moffitt Cancer Center at the Villages Health System;

Nancy Moreland, Manager of Leesburg Regional Medical Center

Medical/Oncology; Barbara Jean Lane, Clinical Coordinator at Florida

Hospital Waterman Cancer Institute. Four Chambers of Commerce

submitted letters, including: Andrew Cripps, Executive Director of the

Sumter County Chamber of Commerce, Inc.; Cathy Hoechst, President of

the Mount Dora Area Chamber of Commerce; Ray San Fratello, President

of the South Lake Chamber of Commerce; Colleen McGinely, Executive

Director of the Tavares Chamber of Commerce. Evadne Tsolo, an

oncology social worker from the Cancer Institute at Florida Hospital

Waterman, sent in a letter of opposition. Three funeral homes were

represented: John Roemmelt, Funeral Director of Steverson, Hamlin &

Hilbish; Terry L. Hensley, Manager of Beyers Funeral Home, Lady Lake;

Roger A. Beyers, President and Owner of Beyers Funeral Homes and

Crematory of Lake and Sumter Counties. Charlotte Wigle, ARNP-C,

submitted a letter. One nursing home--Bill Mobley, Administrator at

Leesburg Health & Rehab, LLC—was represented.


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Seven businesses sent in letters, including: Lucille M. Espey-Francis,

Attorney at Law; Catherine G. Kyle, Kyle Promotions; H. Scott Smith,

MBA Business Solutions; Gregory A. Yager, General Manager of Plaza

Cadillac; Thomas J. Popieski, Area President of BankFIRST; David L,

Weiss, CPA at Weiss Retirement Strategies; Vann Gannaway of Vann

Gannaway Chevrolet, Inc. Ten doctors submitted letters: Dr. William H.

Weaver, Carefirst Family Practice; Dr. William Finlayson III; Dr. Bruce M.

Weaver, Carefirst Family Practice; Dr. Peter Amos Ankoh; Dr. Herman M.

Flink, Radiation Oncologist at InterCommunity Cancer Centers; Dr.

Frank Pellegrino; Dr. Christopher T. Soprenuk; Dr. Ahmed Al-Hazzouri of

Florida Cancer Specialists & Research Institute; Dr. Bobby E. Harrison,

Radiation Oncologist at InterCommunity Cancer Centers; Dr. Maria

Bello. Two non-profit organizations sent in letters Linda H. Krupski,

President of LovExtension, Inc. and H. Scott Smith, Treasurer of Golden

Triangle Kiwanis Foundation. One Senior Home Care sent in a letter,

Robert Lowe, President and Owner of BrightStar of Lake County.

C. PROJECT SUMMARY

Compassionate Care Hospice of Lake and Sumter, Inc.

(CON #10140), a development stage corporation, proposes the

establishment of a new hospice program in Hospice Service Area 3E. The

applicant is a wholly owned subsidiary of Compassionate Care Group,

Ltd. which was founded in 1993 and operates 32 programs in 21 states.

Compassionate Care Hospice is licensed to serve patients in Hospice

Services Area 6B (Polk, Highlands and Hardee Counties).

The applicant is proposing total project costs of $142,965 with year one

operating costs of $1,348,681 and year two costs of $3,102,696.

Schedule C includes the following conditions:

1. The applicant will implement its Cardiac Connections program

immediately upon licensure. It will be made available to all eligible

residents with a qualifying cardiovascular disease. As part of this

implementation the applicant will ensure:

(a) The medical director of Compassionate Care’s Cardiac

Connections Program will be a cardiologist.

(b) The Cardiac Connections Program will have a licensed nurse

practitioner.


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(c) At a minimum, Compassionate Care will hold quarterly

meetings for area cardiologists to maintain open

communications with the community cardiologists to

continue to educate them about options in end of life care for

their patients.

(d) At a minimum, Compassionate Care will coordinate with

local hospitals’ staff and/or physicians on a monthly basis to

review the Cardiac Connections Program and how it may be

benefiting both the hospital and the patient in terms of

reduction in readmission rates, program success and other

measure to be determined.

(e) Cardiac Connection Program patients will receive daily

communication from Compassionate Care staff either via an

in-person visit, or by telephone if an in-person visit is not

scheduled on a particular day.

(f) All Cardiac Connections Program patients will have a

Cardiac Comfort Kit with them in their home.

(g) Compassionate Care will prepare an annual report for the

Agency for Health Care Administration addressing how

hospital readmissions for heart failure have decreased in the

subdistrict relative to the Compassionate Care cardiac

admissions.

2. Compassionate Care Hospice Group, Ltd. will implement its

Pathways to Compassion Program immediately upon licensure of

Compassionate Care, which will be made available to all eligible

Lake and Sumter County residents.

3. Compassionate Care will implement its Veterans Outreach

Program immediately upon licensure as detailed within CON

application #10140.

4. The applicant has conditioned approval of this application on the

provision that it will become accredited by CHAP upon

certification.4

5. Compassionate Care will provide a home health aide ratio above

NHPCO (National Hospice and Palliative Care Organization)

guidelines at an average of 10 hours per patient per week.

6. Compassionate Care will not participate in fundraising activities in

Subdistrict 3E.

7. Compassionate Care will not build or operate freestanding hospice

facilities in Subdistrict 3E.

4 Per http://www.healthfinder.gov/orgs/HR3805.htm, The Community Health Accreditation Program, Inc. (CHAP) is an independent, not for profit accrediting body for community-based health organizations. Benefits of accreditation by CHAP include 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.

http://www.healthfinder.gov/orgs/HR3805.htm


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Harbor Light Hospice of Florida, Inc. (CON #10141), a recently

created, private corporation is seeking to establish a new hospice

program in Hospice Service Area 3E. Harbor Light states that while it is

a new corporate entity in Florida, it is an experienced and well-qualified

hospice provider with five separate entities providing hospice services

from 19 locations in eight states. The applicant notes that 16 of these

hospice programs were start-ups.

Harbor Light is proposing total project costs of $176,460 with year one

operating costs of $805,148 and year two costs of $2,134,559.


The applicant will provide supportive hospice services, such as, but

not limited to, palliative radiation therapy and palliative

chemotherapy and other supportive therapies related to the patient’s

terminal diagnosis.

The applicant will provide continuous care.

The applicant will provide hospice services 24 hours a day, seven days

a week including weekend care as indicated by the patient’s medical

condition.

The applicant will immediately implement its Quality

Assurance/Performance Improvement plan including the following

assessments: pain management, family satisfaction, employee

satisfaction and referral source satisfaction.

The applicant will make available a range of non-covered

supplementary therapies such as, but not limited to: pet, music,

massage, aroma and other holistic treatments.

The applicant will establish a local ethics committee within the first

year of operation.

The applicant will commit to at least 0.5 FTE of staff manpower for

development efforts regarding community bereavement programs in

the local market. The bereavement programs will be broadly based to

extend beyond the families of patients admitted to Harbor Light.

These programs will be an extension of the programs currently offered

in the hospice service area. The applicant will provide bilingual staff

to provide bereavement services to the Hispanic population, including

Hispanic children. At a minimum, one bereavement group consisting

of approximately eight sessions will be offered by the end of the first

year of operation. As the bereavement client census increases after

one year, full time staff will be employed.


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The applicant will provide bilingual or multilingual staff resources to

ensure that hospice services and hospice education or support

programs are available to all segments of the service area population

regardless of language/ethnic heritage.

The applicant will commit to at least 0.5 FTE of staff manpower for a

community education specialist, expanding community awareness of

hospice services and educating medical staff, community leaders and

potential hospice patients as to the benefits of and availability of

hospice care.

The applicant will commit to the development of a satellite office by

the 18th month of operation.

The applicant commits to become accredited by the Joint Commission

within its first year of operation.

The applicant commits to sponsoring four education seminars per

year for physicians, long-term care facilities and assisted living

facilities. The focus of these seminars is to educate the local health

care community on the provision of hospice services within assisted

living facilities and other long-term care facilities: a coordinated plan

of care for the patient, increase support for the patient/family/facility

staff and the provision of equipment, medication and supplies.

The applicant commits that it will not establish any new hospice

housing facilities during the first five years of its operation.

The applicant commits that it will not solicit community funds in

support of its hospice operations. Any unsolicited donations received

will be dedicated directly to the enhancement of Harbor Light Florida

programs in Lake/Sumter.

The applicant will commit to the provision of the following programs

focused on special needs populations:

o Alzheimer’s/Dementia program will be offered

o Hispanic/Latino program will be provided as well as Spanish

translations of its patient handbook, website and brochure

o Palliative Care program will be offered

o Cardiac program will be offered

o Deaf and Hearing Impaired Program will commit to having a

Sorenson VRS device and TTY device available at each one of its

locations. In addition, the applicant will employ bilingual ASL and

ESL-speaking staff in the event Harbor Light staff are unavailable.


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The applicant will utilize appropriately educated and trained

interpreters and commits to provide specialized training and

resource tools for staff working with individuals with hearing

impairment to enhance the provision of hospice care to such

individuals. Harbor Light commits to spend $10,000 plus the cost

of a community educator to work with the medical community on

deaf and hearing impaired issues

o Military Veteran’s Program including participation in We Honor

Veterans as well as a commitment to hiring veterans

Hospice of Marion County, Inc. (CON #10142), a not-for-profit

corporation, proposes the establishment of new hospice program in

Hospice Service Area 3E. The applicant has been a hospice provider in

Marion County for 29 years.

HMC is proposing total project costs of $292,179 with year one operating

costs of $1,746,402 and year two costs of $3,100,487.


1. Commitment to extend the Partners in Care/Together for Kids

program to Subdistrict 3E.

2. Commitment to extend specialized chronic disease certification to

Subdistrict 3E and to have completed at least five workshop series

by the end of the second year of operations.

3. Commitment to establish a dedicated hospice inpatient unit in a

hospital or skilled nursing facility, or freestanding hospice house in

Subdistrict 3E once an average daily census level of 150 has been

attained for a six-month period. Fulfillment of this condition will be

dependent upon: (a) successfully negotiating a lease with a willing

facility partner or (b) obtaining certificate of need approval for a free

standing facility and subsequent licensure from the Agency for

Health Care Administration.

4. Commitment to use the profits of the Thrift Store, located in The

Villages, to support non-reimbursed programs and charity care in

Subdistrict 3E.

5. Commitment to make available palliative care consultation services

(on an inpatient and/or outpatient basis) to patients in Subdistrict

3E within the first two years of operation.


15

6. Commitment to offer a separate children’s bereavement camp to the

Lake and Sumter community. This meaningful day camp provides

enhancements to traditional bereavement services, especially for

those children experiencing problematic grief. The children’s

bereavement day camp will coordinate with the Partners in

Care/Together for Kids program to ensure siblings of these patients

are also served.

7. Commitment to actively participate in community activities,

including education sponsorship, in the amount of $10,000 the first

year of operations and $15,000 by the end of the second year of

operation.

8. In collaboration with the Community Health IT Strategic Partners,

commitment to work with other health care providers in Subdistrict

3E to establish a health information exchange.

9. Commitment to extend the We Honor Veterans program into

Subdistrict 3E.

10. Commitment to extend HMC’s existing special disease programs for

heart failure, pulmonary disease, Alzheimer’s/dementia, including

the telemonitoring program into Subdistrict 3E.

VITAS Healthcare Corporation of Florida (CON #10144), a for-profit

entity, proposes the establishment of a new hospice program in Hospice

Service Area 3E, Lake and Sumter County. The proposed hospice

program will operate as an extension of the VITAS Healthcare

Corporation of Florida (VHCF) hospice program that has been operating

in Florida for the past 30 years. The applicant is currently licensed to

operate hospice programs in 16 Florida counties. VITAS Healthcare

Corporation, the applicant’s parent organization, operates 52 hospice

programs in 18 states and the District of Columbia.

VHCF is proposing total project costs of $881,036 with year one



1. VHCF will provide at least five percent of its total patient days as

continuous care by year two.

VHCF will guarantee that at least 65 percent of patients admitted

have non-cancer diagnoses.


16

2. VHCF will meet exceed the statutory requirement in 400.60501,

Florida Statutes. Seventy percent or more of patients who report

severe pain (seven to 10 on the World Health Organization pain

scale) will report a reduction to five or less on the pain scale within

48 hours after admission.

3. A VHCF staff member or volunteer will attend at least 90 percent of

all deaths to ensure patients do not die alone.

4. VHCF will achieve an overall patient satisfaction score of 90

percent or above on the patient’s family’s evaluation of care while

under the care of VITAS.

5. VHCF will achieve an overall registered nurse satisfaction score of

90 percent or above on patient’s family satisfaction with the nurse

while under the care of VITAS.

6. VHCF will implement a pet therapy program to begin immediately.

PetPals is a program where screened dogs visit shut-ins, nursing

homes, assisted living facilities, adult day care center and

Alzheimer patients.

7. VHCF will establish a satellite hospice office in Sumter County

during the first year of operation.

8. VHCF will implement a TeleCare Program consisting of 24/7 nurse

availability to begin immediately.

9. VHCF will establish a Local Ethics Committee to begin upon

certification.

10. VHCF will implement CarePlanIT, a handheld bedside information

system, by the end of the second year of operation.

11. VHCF will implement VITAS Palliative Care Solutions in Subdistrict

3E by the end of the first year of operations.

12. VHCF will provide palliative radiation, chemotherapy and

transfusions as appropriate for treating symptoms.

13. VHCF will commit to having every patient being assessed by a

physician within 24 hours of admission to the hospice. Medical

directors provide patient visits in their residence.

14. The medical director will be board-certified in hospice or palliative

care medicine, or apply for board certification within five years of

employment.

15. By the second year of operation, 50 percent of all supervisory

nurses will attain certification in hospice and palliative care

nursing. RNs will be encouraged to become certified in Hospice

and palliative care nursing.

16. A Master’s of Divinity or equivalent graduate degree from an

accredited seminary or theological school will be required for

chaplains.


17

17. Social workers will be licensed clinical social workers or Master’s

level.

18. Bereavement services will be available to the family beyond one

year after the death of a patient if needed.

19. VHCF agrees that it will not engage in any fundraising events or

campaigns to obtain charitable contributions from residents of the

subdistrict. VHCF will respond to inquiries from persons seeking

to make charitable contributions for hospice services with

information on relevant 501(c)(3) organizations that benefit Florida

residents.

20. VHCF will establish a Clinical Pastoral Education program to begin

immediately.

21. VITAS will make a charitable contribution in the amount of

$190,000 to Lake and Sumter Community College to fund an

endowed teaching chair, scholarships and ongoing education and

training for nursing students. This funding will be provided during

the first five years of licensure.

22. VITAS will make a charitable contribution to the United Way of

Lake and Sumter in the amount of up to $225,000 during the first

two years of licensure. Up to $25,000 will be used to fund a

survey assessment of senior needs. Additionally, based on the

community projects geared toward seniors that are identified by

the assessment, VITAS will fund up to $100,000 per year for two

years to offset the expected costs of such programs.

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. The applicants’ proposed conditions are as they stated.

However, Section 408.043 (4) Florida Statutes states that “Accreditation by

any private organization may not be a requirement for the issuance or

maintenance of a certificate of need under ss. 408.031-408.045.” Also,

many of these conditions are required hospice services and as such would

not require condition compliance reports.


18

Should a project be approved, the applicant’s proposed conditions would be

reported in the annual condition compliance report as required by Rule

59C-1.013 (3) Florida Administrative Code. Section 408.606 (5) Florida

Statutes states that “The agency may deny a license to an applicant that

fails to meet any condition for the provision of hospice care or services

imposed by the agency on a certificate of need by final agency action,

unless the applicant can demonstrate that good cause exists for the

applicant’s failure to meet such condition”.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review

criteria found in Section 408.035, Florida Statutes; and applicable rules

of the State of Florida, 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 (3) (b), Florida Administrative Code, prohibits any

amendments once an application has been deemed complete. The

burden of proof to entitlement of a certificate rests with the applicant.

As such, the applicant is responsible for the representations in the

application. This is attested to as part of the application in the

Certification of the Applicant.

As part of the fact-finding, the consultant, Marisol Novak, analyzed the

application in its entirety with consultation from financial analysts,

Derron Hillman and Eric West, who evaluated the financial data.


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E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed projects

with the criteria found in Florida Statutes, Sections 408.035 and

408.037; applicable rules of the State of Florida, Chapter 59C-1 and

59C-2, Florida Administrative Code.

1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed

need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C-1.0355, Florida Administrative Code.

In Volume 38, Number 13 of the Florida Administrative Weekly dated

March 30, 2012, a hospice program need of one was published for

Service Area 3E for the July 2013 Hospice Planning Horizon. Service

Area 3E is currently served by Cornerstone Hospice and Palliative Care.

Each co-batched applicant is applying in response to published need for

a hospice program in Hospice Service Area 3E, Lake and Sumter

Counties. However, all applicants provide additional arguments in

support of need for their projects as discussed below.

Below are population estimates for Lake and Sumter Counties, Hospice

Service Area 3E, from July 2012 to July 2017.

Population Estimates for Lake County, Sumter County and Florida

July 2012 - July 2017 Lake County

Age Group

Year Change

2012 2017 Number Percent

Under 65 231,103 265,164 34,061 14.7%

65+ 73,576 88,378 14,802 20.1%

Lake County Total 304,679 353,542 48,863 16.0%

Sumter County

Age Group

Year Change


Under 65 54,568 58,817 4,249 7.8%

65+ 46,180 61,087 14,907 32.3%

Sumter County Total 100,748 119,904 19,156 19.0%

Service Area Subdistrict 3E

Age Group

Year Change


Under 65 285,671 323,981 38,310 13.4%

65+ 119,756 149,465 29,709 24.8%

Service Area Total 405,427 473,446 68,019 16.8%

State of Florida

Under 65 15,703,051 16,609,626 906,575 5.8%

65+ 3,425,139 4,009,870 584,731 17.1%

State Total 19,128,190 20,619,496 1,491,306 7.8% Source: AHCA Florida Population Estimates 2010-2025, published February 2012.


20


indicates that despite the increasing resident deaths in Hospice Service

Area 3E, admissions to the existing hospice have declined between 2009

and 2011, by 5.8 percent (162 admissions). Applying the fixed need

formula to Hospice Service Area 3E results in the following computation

and outcome:

Subdistrict 3E Hospice Utilization

Current Utilization and Projected Need July 2013 Batching Cycle

Subdistrict 3E Provider

Under 65 with

Cancer

65+ with Cancer

Under 65 Non-

Cancer

65+ Non-Cancer

Total

Projected Hospice Patients 293 872 163 1,913 3,241

Cornerstone Hospice and Palliative Care 286 801 150 1,581 2,817

Unserved Hospice Patients 7 71 13 332 424

Net Need (if Unserved Hospice Patients > 350) 1 Source: CON application #10140, page 11.

The applicant notes that more than 81 percent of the projected unserved

hospice patients are in the non-cancer category, with 332 incremental

non-cancer related hospice admissions age 65+ that will not be admitted

by the existing provider.

Compassionate Care uses the 2010 Medicare claims data released by the

Centers for Medicare and Medicaid Services (CMS) to isolate

Cornerstone’s Lake and Sumter demographic and patient information.5

The applicant notes that this is not 100 percent of subdistrict patients

but it cites that 88 percent of Cornerstone’s CY 2011 admissions were

Medicare patients. Therefore, Compassionate Care maintains that this

data provides an accurate portrayal of Cornerstone’s overall utilization

and is used as the proxy for the organization’s operation in Subdistrict

3E.

The applicant indicates that according to Medicare data, Cornerstone

had 2,119 admissions with 1,834 deaths and 285 patients discharged

alive in calendar year 2010. Compassionate Care provides a comparison

between Cornerstone’s Medicare deaths and Lake and Sumter County

65+ deaths by disease category. The applicant notes that 1,860 elderly

persons in Hospice Service Area 3E died while not involved in hospice

service and 54 percent of those deaths were cardiac patients. See the

table below.

5 The applicant notes that the 2011 Hospice Annual Report published by the Department of Elder Affairs is reported on an aggregated basis. Cornerstone reports with its other programs in Hospice Service Areas 6B and 7B.


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Hospice Service Area 3E Resident Deaths by Disease Category

Ages 65+ for Calendar Year 2010

Disease Category

3E Resident

Deaths Ages 65+

Cornerstone

Medicare Deaths

Deaths Not on Hospice

Percent of Deaths Not on

Hospice

Cardiac 1,219 214 1,005 54.0%

Respiratory 319 103 216 11.6%

Cancer 949 616 273 14.7%

Neurological 203 156 47 2.5%

Alzheimer’s 202 188 14 0.8%

Other/Diabetes/ Renal 802 497 305 16.4%

Total Deaths 3,694 1,834 1,860 100.0% Source: CON application #10140, page 13.

Compassionate Care contends that Cornerstone provides a

disproportionately low level of hospice care to cardiac patients compared

to all other disease cohorts. The applicant states that only 17.6 percent

of all of the subdistrict’s 65+ residents who died of cardiac disease in

calendar year 2010 were provided hospice care compared to 50 percent

of the total resident deaths 65+ who received hospice care.

Compassionate Care indicates that when cardiac cases are omitted from

the calculation, 66 percent of non-cardiac related 65+ deaths in Hospice

Service Area 3E were admitted to Cornerstone reflecting a 48 point

disparity between non-cardiac penetration and cardiac penetration rates.

See the table below.

Hospice Service Area 3E Resident Deaths and Hospice Penetration Rates by Disease

Category Ages 65+ for Calendar Year 2010

Disease Category

3E Resident Deaths

Ages 65+

Cornerstone

Medicare Deaths

Percent of Deaths Served by

Cornerstone Hospice

Cardiac 1,219 214 17.6%

Respiratory 319 103 32.3%

Cancer 949 676 71.2%

Neurological 203 156 76.8%

Alzheimer’s 202 188 93.1%

Other/Diabetes/ Renal 802 497 62.0%

Total Deaths 3,694 1,834 49.6%

Total Deaths Less Cardiac 2,475 1,620 65.5% Source: CON application #10140, page 13.

The applicant maintains that, had the 1,219 age 65+ residents who died

from cardiac disease accessed hospice at the overall non-cardiac

subdistrict penetration rate of 65.5 percent—there would have been 584

additional cardiac admissions to Cornerstone Hospice in calendar year

2010. See the table below.


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Estimate of Cardiac Patients to be Served by Hospice

Based on the Non-Cardiac Penetration Rate Subdistrict 3E for Calendar Year 2010

Subdistrict 3E Cardiac Deaths, Age 65+ 1,219

Overall Non-Cardiac Subdistrict 3E Percent of Deaths Serviced by Hospice 65.5%

Number of Cardiac Death to be Served by Hospice if at 65.5% penetration 798

Actual Cardiac Deaths Served by Hospice 214

Incremental Cardiac Deaths that could be Served by Hospice 584 Source: CON application #10140, page 14.

Compassionate Care states that in terms of total cardiac deaths, Sumter

County’s cardiovascular deaths have increased nearly 20 percent and

Lake County’s nearly five percent between 2008 and 2010—an 8.2

percent increase for Hospice Service Area 3E. The applicant notes that

this is in contrast to the State of Florida for the same period of time

whose cardiovascular deaths declined 1.4 percent. See the table below.

Major Cardiovascular Related Deaths

Calendar Years 2008-2010 Service Area 2008 2009 2010

Lake County 1,016 1,045 1,064

Sumter County 306 317 366

Subdistrict 3E 1,322 1,362 1,430

State of Florida 54,107 53,351 53,330 Source: CON application #10140, pages 15-16.

The applicant cites 2009 joint recommendations from the American

Heart Association and the American College of Cardiology for patients

with refractory end stage heart failure that identifies “options for end-of-

life should be discussed with patient and family” as one of the guidelines

for the proper management of end stage heart disease. Based upon this

guideline, Compassionate Care Hospice developed its Cardiac

Connections Program to provide an option for end stage cardiac patients

and their families.

Compassionate Care asserts that end-stage heart disease patients

require hospice as urgently as patients with the most serious types of

cancer. A subset of cardio vascular disease is congestive heart failure

affecting 5.7 million people annually in the U.S. of which, between 75

and 80 percent are 65+. The applicant notes that heart failure is the #1

cause of hospitalizations for people 65+ accounting for 6.5 million

hospital days and $27.9 billion in total direct and indirect Medicare costs

each year.


23

The applicant cites a study that finds that cardiovascular disease

prevalence is projected to increase substantially between 2010 and

2030—by 25 percent.6 See the table below.

Projections of Crude Cardiovascular Diseases Prevalence by Percent

2010-2030 in the U.S. Year

All Cardiovascular

Disease

Hypertension

Coronary

Heart Disease

Heart

Failure

Stroke

2010 36.9 33.9 8 2.8 3.2

2015 37.8 34.8 8.3 3.0 3.4

2020 38.7 35.7 8.6 3.1 3.6

2025 39.7 36.5 8.9 3.3 3.8

2030 40.5 37.3 9.3 3.5 4.0

% Change 9.9% 9.9% 16.6% 25.0% 24.9% Source: CON application #10140, page 19.

Compassionate Care indicates that the mortality rate, at year one, is

higher for heart failure than other illnesses—approaching that of

pancreatic cancer. In addition, an estimated 65 percent of all hospital

admissions of patients age 65+ are diagnosed with heart failure

nationally with a 30-day rate of readmission of 24.8 percent for Medicare

patients. The applicant asserts that heart failure is the number one

reason for readmission in the Country with Lake/Sumter Counties being

no different.

The applicant states that between July 1, 2007 and June 30, 2010, the

four Lake and Sumter acute care hospitals had a weighted average

Medicare readmission rate for heart failure of 25.1 percent.

Compassionate Care presents each specific Medicare heart failure

readmission rate:

Leesburg Regional Medical Center: 26.6%

The Villages Regional Hospital: 25.5%

Florida Hospital Waterman: 21.5%

South Lake Hospital: 27.2%

Compassionate Care indicates that heart failure is the leading cause for

hospital readmissions and therefore the costliest to CMS. Currently CMS

penalizes all hospitals for any heart failure Medicare readmission within

30 days of discharge through claims denial or consolidating with primary

admission. Thomson Reuters estimates that the cost of each hospital

readmission is $5,000 to a hospital—a cost savings to CMS but a strain

to the hospital provider.

6 Forecasting the Future of Cardiovascular Disease in the United States: A Policy Statement from the

American Heart Association by Hendenreich; et.al., 2011.


24

The applicant states that the four acute care hospitals in Lake and

Sumter Counties readmitted 843 Medicare heart failure patients within

30 days of original discharge resulting in aggregated reimbursement loss

to these hospitals of $4.2 million dollars between July 1, 2007 and

June 30, 2010.7 See the table below.

Heart Failure Readmission Impact Lake and Sumter County Hospitals

Medicare Patients Discharged Between July 1, 2007-June 30, 2010 Heart Failure Patients

Leesburg Regional Medical Center

The Villages

Regional Hospital

Florida Hospital

Waterman

South Lake Hospital

Total Lake and Sumter

County Hospitals

Medicare Admissions 1,338 708 919 400 3,365

Rate of Readmission 26.6% 25.5% 21.5% 27.2% 25.1%

Readmissions 356 181 198 109 843

CMS Estimate per

Readmission

$5,000

Fiscal Implication $1,779,540 $902,700 $987,925 $544,000 $4,214,165 Source: CON application #10140, page 22.

Compassionate Care indicates that the Patient Protection and Affordable

Care Act will penalize up to one percent of all inpatient Medicare

payments starting in Federal Fiscal Year 2013 for all hospitals with

readmission rates exceeding the national average for heart failure, acute

myocardial infarction or pneumonia. The applicant contends that these

penalties could far exceed the current penalty/lost reimbursement of

$5,000 per patient.

The applicant states that CMS has estimated that the Cardiac

Connections Programs have saved $22,000 per patient admitted

resulting in a net saving to CMS of $24.2 million—the current 300

patients enrolled in the program will have a savings of $6.6 million. The

$22,000 savings is due to the fact that these patients are enrolled in end-

of-life care and treated throughout the rest of their days by hospice.

Compassionate Care asserts that this savings is not related to the

hospital claims denial discussed above.

Compassionate Care quantifies the specific savings for Lake and Sumter

Counties by stating that the estimated 165 Cardiac Connections Program

patients for the proposed program would equate to a $3,630,000 annual

savings to CMS as well as a $195,000 annual savings to the area

hospitals.

7 The applicant cites data published by the U.S. Department of Health and Human Services.


25

The applicant states that it was rated #1 (out of 53 cardiac hospice

programs) by CMS in November 2011 for its cardiac care and results.

Cardiac Connections is a heart failure home management program

serving patients and the medical community in recognizing the unique

needs of individuals suffering from advanced heart failure. The primary

goals of the Cardiac Connections program are as follows:

Break the cycle of emergency room visits and hospitalizations

Manage anxiety

Comfort the patient’s family

Improve the patient’s functional status

Alleviate dyspnea (shortness of breath)

Alleviate pain

Since inception in November 2009, Compassionate Care indicates that

Cardiac Connections has had (in aggregate) more than 1,100 patients

with 300 currently enrolled. The applicant notes that the readmission

rate of patients enrolled in the Cardiac Connections Program is only one

percent while nationally for heart failure it is 24.8 percent and 25.1 for

the four acute care hospitals in Lake and Sumter County.

Compassionate Care asserts that Cardiac Connections will help Lake and

Sumter County residents by providing clinical leadership team experts,

unmatched solutions and a specialized cardiac formulary. The Cardiac

Connections team are experts in end-stage heart disease and committed

to the proper management of these patients at the end-of-life.

The applicant states that Cardiac Connections program patients have an

average length of stay of 83 days, primarily are not inpatients, half use

continuous care occasionally (two days over the course of enrollment)

and only a small percent reside in nursing homes. Compassionate Care

presents the attributes that the proposed Cardiac Connection program in

Hospice Service Area 3E will have:

Clinical management of the patient will be overseen by an advanced

nurse practitioner who is cardiac certified—this person will visit the

patient one to two times per week and additionally as needed.

Patients will be evaluated by a cardiac nurse practitioner upon

admission.

The hospice physician, a cardiologist, will visit the patient at home

within one week of admission to the hospice program.

The physician appointed as medical director of Cardiac Connections

at Compassionate Care will be a board-certified cardiologist.

Each patient in the Cardiac Connections Program will be seen by a

home health aide for two hours a day, Monday through Friday.

Each patient will have a dietary consult from a registered dietician.


26

Each patient will be evaluated by a physical therapist.

Each patient will undergo a nutritional consult.

Holistic therapies to reduce patient’s anxiety and other symptoms

including massage and music therapy will be provided.

Compassionate Care Hospice staff will maintain daily contact to

monitor symptoms—all after-hour symptom calls will receive a

nursing visit.

Patient and family support will be readily available with social services

and pastoral care.

Every Cardiac Connections patient will receive a Cardiac Comfort Kit

to be kept in their place of residence in the case of emergency

containing specific medication. The Cardiac Comfort Kit is distributed

to every patient but has only been used in one percent of all Cardiac

Connections patients.

Compassionate Care notes that eight cardiologists from Lake and Sumter

Counties have indicated support for the proposed program, six explicitly

addressing the need for the Cardiac Connections program to

accommodate their terminally-ill cardiac patients. These cardiologists

are on staff at each of the four short-term acute care hospitals in Lake

and Sumter Counties.

The applicant asserts that in addition to the Cardiac Connections

program, it still will be a full-service hospice serving patients of all

diseases. Compassionate Care maintains that the existing provider in

Hospice Service Area 3E has lost its prior level of focus on reaching

cancer patients, consistent with its overall admission decline. See the

table below.

Cornerstone Hospice in Hospice Service Area 3E Cancer Admissions

Ages 65+ Calendar Year 2009-2011

2009 2010 2011 2009-2011

Cancer Admissions 904 810 801 ---

Percent Change from Prior Year --- (10.4%) (1.1%) (11.4%) Source: CON application #10140, page 30.

Compassionate Care states that it will provide care for all patients,

including cancers of all forms. The applicant states that its’ Pathways to

Compassion Program provides palliative care to both hospice patients

and to non-terminal, non-hospice patients. The goal is to provide

symptom relief and patient comfort during any state of illness with the

intent of improving quality of life for the patients and families.

Compassionate Care indicates that this program increasing hospice

penetration through a non-hospice option acting as a bridge to hospice

care since it can be offered before end-of-life care is absolutely necessary.


27

The applicant indicates that it was not able to undertake marketing or

referral development prior to licensure in Subdistrict 6B.8 Therefore, it

presents admissions and patient days for this start-up from July 2011 to

April 2012.9 The applicant notes that during this time it had an average

length of stay of 66 days. Compassionate Care envisions a similar

environment in Subdistrict 3E upon CON application #10140’s approval.


Compassionate Care Hospice Subdistrict 6B Program

Start-Up Utilization by Month Month Admissions Patient Days Average Daily Census

July 2011 12 619 20.0

August 2011 20 814 26.3

September 2011 15 943 31.4

October 2011 11 1,019 32.9

November 2011 16 1,089 36.3

December 2011 12 1,170 37.7

January 2012 13 1,078 34.8

February 2012 19 1,249 43.1

March 2012 14 1,143 36.9

April 2012 24 1,161 38.7

Total 156 10,285 33.7 Source: CON application #10140, page 34.

The applicant states that its organization has extensive experience in

providing hospice services in markets with specific needs whether the

need stems from a gap in disease specific care or a specific

demographic/environment. The parent believes that patients are entitled

to live as fully and as comfortably as possible and the hospice will

provide the special care and services that makes those choices possible.

Compassionate Care states that the parent provides a comprehensive

program, designed to support the patient and their family during a most

difficult time. It provides four levels of care: respite, general inpatient,

routine and continuous care. Care is provided based on the patient’s

individual needs by a highly skilled interdisciplinary team consisting of:

physicians, nurses, social worker, counselors, chaplains,

physical/occupational therapists, pharmacists, dieticians, home health

aides and volunteers.

The applicant indicates that it takes care of patients primarily in their

home—an individual’s home or apartment, a long-term care facility or

assisted living. Compassionate Care presents a list of programs it

provides including:

8 Compassionate Care states this was a stipulated condition to its settlement agreement with an existing provider. 9 This hospice program was licensed February 22, 2011.


28

First Night at Home

Cardiac Connections

Promise Program (end-stage renal disease program)

Pulmonary Connections Program

Veterans Outreach

Compassionate Care 4 Kids

Volunteer Services

Bereavement Services

Rainbows (bereavement support program for children)

Pathways to Compassion (palliative care program)

Transitions (community service program)

Massage Therapy

Music Therapy

Energetic Care

Sacred Spaces

Comfort Corners

Guided Imagery

Reminiscence Therapy

Pet Therapy

Aromatherapy

Reflexology

Hypnotherapy

The applicant notes that it will consider implementing a program to

provide palliative comfort and care to terminally-ill patients housed at

the Lake County Correction Facility in Clermont should there be a

proven gap in service for hospice care.

Compassionate Care states that Cornerstone, the sole existing provider,

has experienced a 3.4 percent decline in admissions in the past two

years in its three hospice service areas. See the table below.

Cornerstone Hospice Admissions Trend by Subdistrict

Calendar Years 2009-2011 Cornerstone Hospice

CY 2009

CY 2010

CY 2011

Percent Change

2010-2011

Percent Change

2009-2011

Subdistrict 3E 2,979 2,958 2,817 (4.8%) (5.4%)

Subdistrict 6B 697 806 771 (4.3%) 10.6%

Subdistrict 7B 689 638 663 3.9% (3.8%)

Total 4,365 4,402 4,251 (3.4%) (2.6%) Source: CON application #10140, page 55.

The applicant states that Cornerstone is a not-for-profit community

hospice that relies on charitable donations from the community to

supplement its services. In addition, Cornerstone owns and operates

four hospice houses in Hospice Service Area 3E. Compassionate Care


29

states that it is a for-profit corporation that has conditioned approval of

CON #10140 on the provisions that it will not participate in fundraising

activities in Subdistrict 3E and will not build or operate freestanding

hospice facilities.

Compassionate Care asserts that it is not seeking to compete with

Cornerstone for admissions; rather it is seeking to work collaboratively

with Cornerstone to ensure enhanced access to hospice care and reduce

the 424 person gap in admissions that exists in the planning horizon.

Compassionate Care’s organization has worked collaboratively with

Cornerstone in the past in Hospice Service Area 6B—the only subdistrict

where Cornerstone has demonstrated an increase in the past two years.

The applicant forecasts that it will have a positive impact on Lake and

Sumter Counties through increased market penetration, increased

consumer/facility education and expanding hospice opportunities for the

underserved population that have compromised access. The applicant

states that it will offer a choice in hospice providers to terminally-ill

residents of Hospice Service Area 3E while targeting the underserved

cardiac patients, cancer patients and others whom have been identified

as having barriers to hospice care.

Compassionate Care forecasts 157 admissions in year one and 366

admissions in year two. The applicant notes that its year two volumes

only represent 7.7 percent of the 4,753 subdistrict deaths forecasted for

the 12 months ending June 30, 2014. Compassionate Care maintains

that this will enable Cornerstone to grow and the applicant to meet the

defined needs of unserved patients.

The applicant indicates that as a small to midsize privately held for-profit

company it has the benefits of achieving economies of scale, but unlike

larger corporate chains it has extremely low overhead and is able to

respond quickly to community needs. The parent company of

Compassionate Care takes a decentralized approach to allow hospices to

act more autonomously unlike larger national chains, such as VITAS,

that are highly centralized.

Compassionate Care notes that it has a sister program in Hospice

Service Area 6B that is contiguous to the south of Hospice Service Area

3E. The applicant indicates that certain economies of scale can achieve

a seamless entry with these existing operations to the south.


30

Compassionate Care notes that two of the co-batched applicants are

without existing operations in the State of Florida, or even in the

southeast.10 The applicant provides the following summaries of each of

the competing co-batched applicants:11

Hospice of Marion County: a local not-for profit that has hospice

operations to the north of Lake and Sumter Counties. Its operating

model is strikingly similar to the existing Cornerstone. It relies on

local fundraising activity for its livelihood. Like Cornerstone, it

operates hospice houses and has freestanding inpatient hospice

facilities. If approved, it would directly compete with Cornerstone for

charitable contributions from within Lake and Sumter Counties and

would have comparable operations in terms of community and

strategy, therefore, not providing a different approach and unique

programs to reach the unserved patients.

Harbor Light Hospice of Florida: a subsidiary of Harbor Light

Hospice based out of Illinois.12 It has no existing or approved

operations in the State of Florida. Based on its website, Harbor Light

appears to be a for-profit company with operations in Illinois, Indiana,

Oregon and Virginia.13

VITAS Healthcare Corporation of Florida: is the country’s largest

hospice provider as well as Florida’s largest hospice provider, serving

16 Florida counties. VITAS is a significantly large company with

program manuals, corporate approach to meeting needs and national

standards. This is evidenced by VITAS’ Hospice Annual Reports

published by DOEA. In each market where it operates in the State of

Florida, VITAS consistently provides only 12-13 percent of its

admissions to patients with end stage heart disease. Compassionate

Care contends that its local community based approach to

programming differentiates it from VITAS and demonstrates that

Compassionate is the more appropriate applicant to meet the defined

need.

Harbor Light Hospice of Florida, Inc. (CON #10141) presents the

following information to document the system limitations and the

rationale that exists to support the proposed hospice program, including:

10 The reviewer notes that Passages Hospice of Central Florida, Inc. was administratively withdrawn on June 21, 2012. The reviewer also notes that Harbor Light Hospice does provide hospice services in Ellijay, Georgia; Dalton, Georgia; and Scottsboro, Alabama. 11 The reviewer did not include the summary regarding Passages Hospice of Central Florida, Inc. 12 Compassionate Care incorrectly identifies this entity as Harbor Lights Hospice of Florida. 13 Harbor Light Hospice has five separate entities providing hospice services in eight states: Virginia, Ohio, Georgia, Alabama, Indiana, Illinois, Nebraska and Oregon.


31

Population, Total and By Age Cohort

The applicant states that the 2012-2015 percentage increase in total

population in Hospice Service Area 3E (10.4 percent or 42,271) is well

above the growth rate projected for District 3 (7.5 percent or 122,576)

and more than double the growth rate projected for the State of Florida

(4.8 percent or 923,614). See the table below.

District 3 Projected Total Population Growth

By Hospice Service Area 2012-2015

Service Area

2012

2015

Absolute Change

Percent Change 2012-2015

3A 579,511 606,714 27,203 4.7%

3B 337,281 365,290 28,009 8.3%

3C 142,481 151,630 9,149 6.4%

3D 176,144 192,088 15,944 9.1%

3E 405,427 447,698 42,271 10.4%

District 3 Total 1,640,844 1,763,420 122,576 7.5%

State of Florida 19,128,190 20,015,804 923,614 4.8% Source: CON application #10141, page 31.

Harbor Light maintains that the 65+ population for Hospice Service Area

3E is projected to grow 13.8 percent (16,476), well above the growth rates

for District 3 at 11.7 percent (45,349) and the State of Florida at 9.5

percent (323,695). See the table below.

District 3 Projected 65+ Population Growth


Service Area

2012

2015

Absolute Change


3A 87,108 97,716 10,608 12.2%

3B 88,396 98,217 9,821 11.1%

3C 46,077 50,048 3,971 8.6%

3D 45,555 50,028 4,473 9.8%

3E 119,756 136,232 16,476 13.8%

District 3 Total 386,892 432,241 45,349 11.7%


The applicant contends that when the population age 75 years and older

is considered, the greatest growth is also projected to occur within

Hospice Service Area 3E (15.5 percent or 7,739)—significantly above

District 3 (11.8 percent or 19,873) and more than double the rate

projected for the State of Florida (7.1 percent or 112,120). See the table

below.


32

District 3 Projected 75+ Population Growth


Service Area

2012

2015

Absolute Change


3A 36,634 40,214 3,580 9.8%

3B 39,628 44,098 4,470 11.3%

3C 21,168 23,322 2,154 10.2%

3D 21,650 23,580 1,930 8.9%

3E 49,912 57,651 7,739 15.5%

District 3 Total 168,992 188,865 19,873 11.8%


Underserved Population: Hispanic Population

Harbor Light maintains that Lake and Sumter Counties are home to a

significant number of Hispanic persons, 11 percent of Lake and Sumter

County’s population were of Hispanic or Latino origin in calendar year

2010. See the table below.

Hispanic Population

Lake County, Sumter County and Florida 2010

Sumter Lake 3E Florida

Population, 2010 as per the US Census 93,420 297,052 390,472 18,801,310

Percent of Persons of Hispanic or Latino origin

as per the US Census

6.0%

12.1%

11%

22.5%

Number of Persons of Hispanic or Latino origin

as calculated by the applicant

5,605

35,943

41,548

4,230,295 Source: CON application #10141, page 35

The applicant cites 2010 Department of Elder Affairs data that indicates

that six percent of the hospice patients in Hospice Service Area 3E were

of Hispanic of Latino origin. Harbor Light states that this is far below the

11 percent of residents who are of Hispanic or Latino origin. Therefore,

the applicant concludes that it is clear that the Hispanic population

remains an underserved group for hospice services.

Harbor Light indicates that it has a specialized team that is currently

developing a program tailored to meet the needs of the Hispanic/Latino

community. The team is headed by Nicole Rosenbaum who holds a

Bachelor Degree in International Studies and Spanish and a Master’s of

Science Degree in Elementary ESL Education, both from the University of

Miami.

The reviewer notes that according to the Department of Health Office of

Vital Statistics Annual Report 2010, Deaths, there were 134 total resident

deaths of Hispanic origin in Lake and Sumter County in calendar year

2010. This represented 2.92 percent of deaths in all age groups in these

counties.


33

Underserved Population: Non-Cancer Patients

Harbor Light asserts that while it is committed to serving the entire

population of Hospice Service Area 3E, it specifically commits to serve

the underserved population of non-cancer patients in both the under 65

and 65+ age cohort. The applicant notes that despite the percent

utilization for non-cancer patients under the age of 65 equaling the state

average, Hospice Service Area 3E ranks 18th out of the 27 hospice service

areas. Harbor Light maintains that there is a clear indication that

improvement in hospice utilization for non-cancer patients under the age

of 65 is needed and achievable.

The applicant contends that there is a greater opportunity to serve the

needs of non-cancer patients over the age of 65 years. Hospice Service

Area 3E ranks 23rd out of the 27 hospice service areas—with only 61.9

percent of patients served, well below the state average of 69.2 percent.

Harbor Light indicates that it will have specialized programs to meet the

needs of specific patient groups, including:

Harbor Light’s Alzheimer’s Disease/Dementia Program

Harbor Light’s Cardiac Program

Harbor Light’s Skin Integrity/Wound Care Program

Special Needs Populations

The applicant states that it is dedicated to meeting the special needs of

Hospice Service Area 3E and has conditioned CON #10141 to that effect.

Harbor Light notes that there are an estimated 61,000 deaf and hearing

impaired individuals who live and work in Lake and Sumter County.14

The applicant commits to the development and implementation of

programs focused on improving access to hospice service by hearing

impaired and deaf persons in Hospice Service Area 3E. The program will

include training on communication differences, competencies and flexible

programming to meet the needs of the deaf and hearing impaired. In

addition, special community outreach efforts, clinical care protocols and

bereavement services for families will be implemented to increase deaf

and hearing impaired participation in hospice.

14 As estimated by the Deaf and Hearing Services of Lake and Sumter Counties, Inc.


34

Harbor Light also identifies veterans as a special needs population as

veterans comprise 29 percent of the Hospice Service Area 3E population

age 65+. See the table below.

Veterans Aged 65+

Hospice Service Area 3E By Gender

2010 Lake Sumter 3E

Men

Veterans, Age 65+ 20,158 11,676 31,834

Total 65+ Population 33,234 20,262 53,496

Percentage of Veterans 61% 58% 60%

Women

Veterans, Age 65+ 672 325 997


Percentage of Veterans 2% 2% 2%

Total Men and Women

Veterans, Age 65+ 20,830 12,001 32,831


Percentage of Veterans 29% 30% 29% Source: CON application #10141, page 28.

The applicant commits to participate in the We Honor Veterans program

and also commits to the hiring of veterans.15

Deaths Served by Hospice

Harbor Light indicates that while there was an increase in the number of

deaths in Hospice Service Area 3E, the number of deaths served by the

sole hospice provider has grown at a lower than expected rate when

compared to District 3 and the State of Florida hospice patient volumes.

The applicant states that Hospice Service Area 3E experienced the

greatest percent increase in the number of resident deaths (11.3 percent)

but with the lowest percentage increase in the number of patients served

by hospice (14.6 percent). See the table below.

15 We Honor Veterans is a program of the National Hospice and Palliative Care Organization in collaboration with the Department of Veterans Affairs inviting hospices, state hospice organizations, Hospice-Veteran partnerships and VA facilities to focus on respectful inquiry, compassionate listening and grateful acknowledgement.


35

Resident Deaths, Hospice Patients and Percentage of Patients Served by Hospice

Hospice Service Area 3E, District 3 and Florida 2006-2010

2006 2010 Absolute Change Percent Change

Hospice Service Area 3E

Deaths 4,120 4,585 465 11.3%

Hospice Patients 2,582 2,958 376 14.6%

% of Deaths Served by Hospice 63% 65%

District 3

Deaths 17,808 18,958 1,150 6.5%

Hospice Patients 10,170 12,800 2,630 25.9%


Florida

Deaths 169,365 172,509 3,144 1.9%

Hospice Patients 93,764 110,377 16,613 17.7%


Source: CON application #10141, page 54.

Hospice of Marion County, Inc. (CON #10142) identifies several key

factors that demonstrate that it is the best applicant to meet the needs of

Hospice Service Area 3E, including:

Not-for-profit status

Regional presence

Vision and commitment

Commitment to quality

Community support

Cost Savings

HMC asserts that it is committed to integrity, compassion,

communication, teamwork and stewardships to those it serves on a daily

basis. The applicant maintains that Hospice Service Area 3E will benefit

from quality initiatives and clinical protocols already established in

Subdistrict 3B to ensure that the highest quality of service will be

delivered.

The applicant notes the wide spectrum of letters of support, over 240,

from community residents and health care professionals. The reviewer

notes that the applicant had 231 unduplicated letters of support and one

unsigned email for its project, 146 are from or serve residents within

Hospice Service Area 3E. HMC states that the proposed program will

implement community education efforts, clinical care protocols and

bereavement services for families to increase participation in hospice for

groups traditionally underserved including Hispanics and Veterans.

The applicant states that it is a not-for-profit organization that has

provided high quality, efficient, patient-centered hospice services in

Marion County for nearly 30 years. HMC notes that Hospice Service

Area 3E shares many demographic characteristics with Marion County,


36

therefore many of the HMC’s current operations can be utilized as a

basis for the programs that will be offered to Lake and Sumter residents.

The applicant maintains that it has existing relationships in the market

and proposes to share its existing resources to maximize economies of

scale.

HMC indicates that there is growing concern among federal regulators

regarding the rapid increase in Medicare hospice expenditures. The

Medicare Payment Advisory Commission (MedPAC) made several findings

regarding this issue, including:16

Medicare spending for hospice care has increased dramatically in

recent years. This spending increase was driven by greater numbers

of beneficiaries electing hospice and by longer stays among hospice

patients with the longest stays.

The structure of Medicare’s hospice payment system makes very long

stays in hospice more profitable for providers than shorter stays.

The Office of Inspector General (OIG) recently completed a study on

hospices that rely heavily on nursing home patients finding that these

hospices are more likely to be for profit and to treat patients with

conditions with longer stays requiring less complex care. The OIG

recommended that CMS both monitor hospices that rely heavily on

nursing home patients and reduce payment rates for hospice services

provided in nursing homes.

The markedly longer stays among assisted living facility residents

(constituting about eight percent of hospice patients) compared with

nursing facility residents is not understood and bears further

monitoring and examination.

The applicant states that its proposed program best addresses the

concerns raised regarding unnecessary utilization of hospice services by

very long-stay patients. HMC is committed to serve all types of patients

requiring hospice care, not just those who are most profitable. The

applicant compares its caseload of hospice patients by setting for

calendar year 2011 with VITAS’ caseload by setting. The applicant

contends that VITAS has a greater focus on serving long-stay patients in

an institutional setting.

16 Medicare and the Health Care Delivery System Report to the Congress, MedPAC, June 2012.


37

Caseload of Hospice Patients by Setting

Hospice Marion County and VITAS Calendar Year 2011

Hospice

Home

Hospital

Hospice Res. Unit

FS IP Hospice Facility

Nursing Home

ACLF

Total

January to June 2011 (number of patients)

Hospice of

Marion County

233

0

0

35

55

61

384

VITAS 2,188 273 0 0 972 1,331 4,764

January to June 2011 (percent of patients)

Hospice of

Marion County

60.7%

0.0%

0.0%

9.1%

14.3%

15.9%

100.0%

VITAS 45.9% 5.7% 0.0% 0.0% 20.4% 27.9% 100.0%

July to December 2011 (number of patients)

Hospice of

Marion County

205

0

0

42

72

61

380

VITAS 2,556 273 0 0 1,023 1,331 5,183

July to December 2011 (percent of patients)

Hospice of

Marion County

53.9%

0.0%

0.0%

11.1%

18.9%

16.1%

100.0%

VITAS 49.3% 5.3% 0.0% 0.0% 19.7% 25.7% 100.0%

Source: CON application #10142, pages 77-78.

The applicant cites a 2011 Department of Elder Affairs Report that stated

that 41 percent of Florida hospice patients were located in nursing

homes or assisted living facilities. HMC indicates that it was below this

percentage while VITAS exceeded the statewide average in all semi-

annual periods in 2010 and 2011. The applicant asserts that the

implications of long-stay Medicare expenditures hold true for Florida’s

Medicaid program. Therefore, HMC concludes that the Medicaid budget

is negatively impacted by inappropriately admitting long-stay Medicaid

patients. However, the applicant’s tables are based on the Agency’s

semi-annual reports, which include one day snap shots, January 1 and

July 1 of calendar years 2010 and 2011. The Department of Elder

Affairs data is based on annual totals which would be more definitive.

HMC states that freestanding inpatient hospice facilities provide a

specialized and compassionate setting for end-of-life care and requires

expenditures over and above the expense of contracting an inpatient bed

in a nursing home or hospital. The applicant notes that while it

currently operates four freestanding hospice facilities, VITAS does not

offer freestanding inpatient hospice facilities in any of the subdistricts it

serves.

The applicant indicates that it will structure services geographically to

address the specific needs in each area of the two counties. HMC

presents demographic trends for Hospice Services Area 3E, including:


38

The total population of Subdistrict 3E is projected to increase by 16.7

percent between 2012 and 2017. The population age 65+ will

increase substantially faster (24.7 percent) over that period. The

applicant’s table below indicates that total population growth is 12.9

percent from 409,790 in 2012 to 462,736 in 2017. The age 65+

population is projected to increase from 114,358 in 2012 to 138,461

residents in 2017 or by 21.1 percent.

The percentage of 65+ residents in Subdistrict 3E is greater than

Florida overall, and this percentage is increasing.

The pediatric population is not increasing as rapidly as the elderly,

but they still represent an important component of the population

whose hospice needs must be addressed.

The percentage growth in Sumter County’s population between 2012

and 2017 is projected to be greater than that of Lake County,

although Lake County will experience higher absolute growth.

The greatest rates of growth will occur in southern Lake and northern

Sumter Counties.

Minorities are growing more rapidly than white residents of each

county. Hispanic residents, in particular, will represent a larger

percentage of the total population by 2017.

HMC indicates that the population of Hospice Service Area 3E is

projected to be 462,736 residents in 2017, a growth of 12.9 percent. The

applicant notes the 65+ population is growing significantly, leading to

greater demand for health care services including hospice. The applicant

maintains that the population growth anticipated in pediatric population

is of particular significance as well. See the table below.

Population by Age Cohort Hospice Service Area 3E

2012-2017 2012 2017 Percent Change

Under 21 85,389 97,479 14.2%

21-64 210,043 226,796 8.0%

65+ 114,358 138,461 21.1%

Total 409,790 462,736 12.9% Source: CON application #10142, page 82 based on ‘Claritas Marketplace’.

The applicant presents the sectional population of Lake and Sumter

Counties by race. HMC especially notes the growing African-American

and Asian populations in Lake County and the growing Asian population

in Sumter County. See the tables below.


39

Population by Race for Lake County

2012-2017 Ethnicity Southern Lake County Central Lake County Northern Lake County

2012

2017

% Change

2012

2017

% Change

2012

2017

% Change

African-American 20,205 26,105 29.2% 18,332 19,457 6.1% 4,968 5,270 6.1%

Native Americans 774 967 24.9% 730 875 19.9% 416 494 18.8%

Asians 6,404 9,489 48.2% 2,480 3,138 26.5% 647 807 24.7%

White Alone 117,339 129,657 10.5% 157,792 168,342 6.7% 49,463 51,285 24.7%

Native Hawaiian

Pacific Islander

178

259

45.5%

125

168

34.4%

18

18

0.0%

Some Other Race 10,236 14,260 39.3% 4,711 6,274 33.2% 2,200 2,740 24.5%

Two or More Races 5,653 7,853 38.9% 3,300 4,134 25.3% 1,220 1,468 20.3%

Total 160,789 188,590 17.3% 187,470 202,388 8.0% 58,932 62,082 5.3%


Population by Race for Sumter County 2012-2017

Ethnicity Southern Sumter County Central Sumter County Northern Sumter County

2012

2017

% Change

2012

2017

% Change

2012

2017

% Change

African-American 622 459 -26.2% 1,772 1,812 2.3% 6,772 6,423 -5.2%

Native Americans 71 67 -5.6% 92 90 -2.2% 216 217 0.5%

Asians 36 46 27.8% 90 109 21.1% 636 916 40.6%

White Alone 7,324 8,356 14.1% 12,900 14,516 12.5% 70,683 87,925 24.4%

Native Hawaiian

Pacific Islander

7

7

0.0%

8

7

-12.5%

24

25

4.2%

Some Other Race 354 421 18.9% 596 754 26.5% 701 802 14.4%

Two or More Races 205 242 18.0% 317 382 20.5% 650 709 9.1%

Total 8,619 9,598 11.4% 15,775 17,670 12.0% 79,682 97,017 21.8%


HMC defined the Hispanic population in Hospice Service Area 3E as an

underserved group because they traditionally use hospice care at a lower

rate than the general population. The reviewer notes that according to

the Department of Health Office of Vital Statistics Annual Report 2010,

Deaths, there were 134 total resident deaths of Hispanic origin in Lake

and Sumter County in calendar year 2010. This represented 2.92

percent of deaths in all age groups in these counties.

The applicant states that Lake County has a significant Hispanic

population of 57,007 (14.0 percent) in 2012 and projected to grow to

75,755 (16.9 percent) in 2017. HMC indicates that a majority of the

Hispanic population lives in southern Lake County. The applicant notes

that the Hispanic population accounts for a lower percentage of the total

population in Sumter County than Lake, with the majority residing in

northern Sumter. See the tables below.


40

Lake County Hispanic Population

2012-2017 Southern Lake Central Lake Northern Lake Total

2012 2017 2012 2017 2012 2017 2012 2017

Non-Hispanic 126,053 140,237 171,877 182,240 52,254 53,828 350,184 376,305

Hispanic 34,736 48,353 15,593 20,148 6,678 8,254 57,007 76,755

Total 160,789 188,590 187,470 20,388 58,932 62,082 407,191 453,060

Percent Hispanic 21.6% 25.6% 8.3% 10.0% 11.3% 13.3% 14.0% 16.9%


Sumter County Hispanic Population 2012-2017

Southern Sumter Central Sumter Northern Sumter Total

2012 2017 2012 2017 2012 2017 2012 2017

Non-Hispanic 7,677 8,480 14,176 15,708 75,884 92,649 97,737 116,837

Hispanic 942 1,118 1,599 1,962 3,798 4,368 6,339 7,448

Total 8,619 9,598 15,775 17,670 79,682 97,017 104,076 124,285

Percent Hispanic 10.9% 11.6% 10.1% 11.1% 4.8% 4.5% 6.1% 6.0%


HMC indicates that the Hispanic population is expected to grow over 33

percent in the Clermont area (southwest Lake County) an over 30

percent in the Leesburg area—where the applicant’s office will be located.

HMC contends that its proposed office location will be poised to serve

this growing demographic group. The applicant states that it will

increase utilization of hospice services among the Hispanic population by

addressing the unique language and cultural needs as well as expand its

existing Marion County programs to Hospice Service Area 3E.

Furthermore, HMC will develop community partnering programs to

ensure education on Hispanic beliefs and traditions along with education

and service to families. The applicant will employ bilingual, Spanish-

speaking staff and provide translated forms and literature.

The applicant states that the number of deaths in Subdistrict 3E has

grown over the past several years, but the increase has not been

consistent across all age groups. Subdistrict 3E total deaths increased

by 12.5 percent from 4,077 in 2005 to 4,585 in 2010. The total number

of deaths from all causes in the age 75 and over cohort grew from 2,434

in 2005 to 2,763 in 2010 (13.5 percent increase). HMC identifies an

increase in particular causes of death during this time period, including:

Chronic lower respiratory disease (increase of 24.3 percent), malignant

neoplasms (increase of 19.1 percent) and Alzheimer’s disease (increase of

15.1 percent). See the table below.


41

Trends in Deaths for Hospice Service Area 3E

2005-2010

Age Group

Cause of Death

2005

2006

2007

2008

2009

2010

Percent Change

2005-2010

Under

19

Cardiovascular Diseases 1 1 0 2 1 2 100.0%

Chronic Lower Respiratory Diseases 1 0 1 0 0 0 -100.0%

Human Immunodeficiency Virus 0 0 0 0 0 0 0.0%

Malignant Neoplasms 1 1 1 0 2 3 200.0%

Alzheimer’s Disease 0 0 0 0 0 0 0.0%

All Causes 55 43 68 50 48 43 -21.8%

20-44 Cardiovascular Diseases 25 18 19 19 28 21 -16.0%

Chronic Lower Respiratory Diseases 0 1 1 1 1 0 0.0%

Human Immunodeficiency Virus 5 4 5 8 8 2 -60.0%

Malignant Neoplasms 22 18 22 19 20 19 -13.6%


All Causes 174 161 156 171 167 150 -13.8%

45-64 Cardiovascular Diseases 183 175 150 172 155 188 2.7%

Chronic Lower Respiratory Diseases 29 14 30 29 18 27 -6.9%



Alzheimer’s Disease 2 0 1 3 0 0 -100.0%

All Causes 628 607 584 719 731 698 11.1%

65-74 Cardiovascular Diseases 244 225 217 196 235 239 -2.0%





All Causes 786 799 806 817 892 931 18.4%

75+ Cardiovascular Diseases 1,042 1,000 909 933 943 980 -6.0%





All Causes 2,434 2,510 2,406 2,561 2,625 2,763 13.5%

All

Ages

Cardiovascular Diseases 1,495 1,419 1,295 1,322 1,362 1,430 -4.3%


Human Immunodeficiency Virus 12 8 10 14 16 10 -16.7%

Malignant Neoplasms 994 1,077 1,034 1,110 1,235 1,202 20.9%


All Causes 4,077 4,120 4,020 4,318 4,463 4,585 12.5%


HMC contends that it is uniquely qualified to serve patients suffering

from chronic lower respiratory diseases as it offers the Inspirations

program specifically designed to care for patients suffering from chronic

lower respiratory diseases through all stages of the disease process. This

program offers specialized services, such as a specialized plan of care,

specially trained nursing teams, nurses on call 24 hours a day,

Telehealth, nutrition consultants, patient and caregiver education and

psycho-social support among other services. The applicant states that it

also has a specialized program to serve Alzheimer’s disease patients

called the Reflections program that offers services such as a specialized

plan of care coordinated with patient’s physician, nursing teams specially

trained in dementia care, nurses on call 24 hours a day, medications and

medical equipment specific for dementia patients, patient and caregiver

education and psycho-social support among other services.


42

The applicant notes that while parts of Lake and Sumter Counties are

experiencing rapid population growth, it will reach out to the more rural

areas of the district as these populations often lack knowledge of the

benefits of hospice care. HMC indicates that it will ensure the rural

portions of Hospice Service Area 3E are addressed through outreach and

education efforts.

HMC states that in 2010, 45.8 percent of white Medicare decedents

utilized hospice services while only 37 percent of Hispanic and 34

percent of African-American Medicare decedents utilized services during

that time. Asian Americans Medicare decedents have the lowest

utilization at 28.1 percent. The applicant states that such utilization

trends suggest that the cultural, religious and philosophical differences

are prevalent and may impact the rate of hospice use. The reviewer

notes that the Department of Health Office of Vital Statistics Annual Report

2010, Deaths, indicates there were 134 total resident deaths of Hispanic

origin in Lake and Sumter Counties in calendar year 2010. This

represented 2.92 percent of deaths in all age groups in these counties.

African-Americans accounted for 245 total resident deaths, or 5.32

percent of deaths in all age groups in these counties.

The applicant states that Hospice Service Area 3E ranks 17th lowest

among the 27 subdistricts in the number of hospice admissions to

reported deaths (a/k/a the hospice penetration rate). HMC notes that

the penetration rate dropped from 66.73 percent in CY 2009 to 64.51

percent in CY 2010. The applicant maintains that there is clearly

potential in Hospice Service Area 3E to increase hospice penetration

rates through greater patient education, outreach to referral sources and

enhancing availability to underserved groups. HMC asserts that

approval of the proposed program will facilitate an increase in hospice

penetration rate with a focus on patients who are appropriate for such

care rather than those who will generate the greatest profitability.

HMC states that it currently serves all age categories and is well suited to

serve the age 65+ population. The applicant indicates that it has a track

record of serving all ethnic groups and cultures and that this sensitivity

to cultural differences will be brought to the residents of Hospice Service

Area 3E. The applicant provides its 2010 admission by age and

race/ethnicity. See the table below.


43

HMC Admissions by Age and Race/Ethnicity

CY 2010

Age Group # of

Patients Percent of Admissions

Race/ Ethnicity

# of Patients

Percent of Admissions

Under 19 2 0.07% White 2,629 91.28%

19-64 336 11.67% Black 173 6.01%

65+ 2,542 88.26% Hispanic 64 2.22%

Total

2,880 Admissions

Other 11 0.38%

Asian 3 0.10%

Total 2,880 Source: CON application #10142, page 103.

The applicant maintains that its admissions grew 6.9 percent between

2009 and 2011—despite Odyssey’s new hospice program in the district.

HMC states that this historical trend indicates that it is able to compete

with new providers and can positively affect future hospice utilization.


Historical Admissions by Provider in Marion County

Year Hospice of Marion County Odyssey Hospice Total

2009 2,535 Not yet operational 2,535

2010 2,731 185 2,916

2011 2,709 208 2,917 Source: CON application #10142, page 104.

HMC states that it has consistently demonstrated its ability to grow

hospice penetration rates in Marion County. In 2004, Marion County’s

penetration rate was 50.5 percent; by 2010 it had grown to 67.9 percent.

The applicant asserts that this increase was directly due to its efforts to

increase community awareness of hospice and to offer innovative

programs to address the diverse needs of the county’s residents. HMC

notes that Hospice Service Area 3E only grew 7.3 percent during this

same time period. However, Marion County did not reach 62 percent of

deaths to hospice admits until 2009 when a new provider entered the

market, while Service Area 3E has consistently averaged over 62 percent

since 2006. See the table below.

Hospice Penetration Rates in Marion, Lake and Sumter Counties

2004-2004 Service

Area

2004

2005

2006

2007

2008

2009

2010 Percent Change

3B Resident Deaths 3,832 3,897 3,990 3,923 4,147 4,077 4,292 --

Hospice Admissions 1,937 1,970 2,233 2,236 2,485 2,535 2,916 --

Percent of Deaths

Served

50.5%

50.6%

56.0%

57.0%

59.9%

62.2%

67.9%

17.4%

3E Resident Deaths 3,783 4,077 4,120 4,020 4,318 4,464 4,585 --

Hospice Admissions 2,164 2,387 2,582 2,673 2,875 2,979 2,958 --

Percent of Deaths

Served

57.2%

58.5%

62.7%

66.5%

66.6%

66.7%

64.5%

7.3%



44

HMC provides projected utilization of the proposed program based on the

following assumptions:

The actual 2010 death rates by age and disease category for

Subdistrict 3E were applied to the estimated population for 2011 and

projected population for 2013, 2014 and 2015 to project deaths. This

rate was held constant throughout the projection period.

These projected deaths were used to determine the estimated and

projected penetration rates. The estimated 2011 penetration rate

showed a significant drop from 2010.

The projected penetration rates are applied to projected deaths to

yield the total projected hospice admissions from 2013-2015.

The projected penetration rates were based on the actual penetration

rates, by age and disease category for the State of Florida and Marion

County. Rates were projected to increase to a similar level to that

achieved by Marion County and the State of Florida in 2010.

Subdistrict 3E’s penetration rate is projected to reach the state’s 2010

rate in 2015.

Projected market shares were applied to the projected total hospice

admissions to calculate the number of admissions by category and

age that HMC would serve. Rates are generally based on the

experience of other hospices in Florida and Odyssey Hospice in

Subdistrict 3B. These market shares reflect the applicant’s ramp up

period and year two’s market share is reflective of the impact the

provider will make in the Subdistrict 3E market. HMC’s market share

projections are very reasonable for a hospice provider with the depth

of experience, community education and outreach programs, quality

services and existing relationship HMC has in the proposed service

area.

The assumed average lengths of stay were multiplied by the projected

admissions to determine the projected patient days. The average

lengths of stay are expected to be 40 days in year one and 52 days in

year two. The lengths of stay assumptions give effect to the start-up

of operations in year one and year two.


45

Projected Utilization for HMC

Subdistrict 3E Year One and Year Two

Projected

2,013 2,014

Hospice Admissions Year One Year Two

Cancer Under 65 209 229

Cancer 65+ 528 577

Non-Cancer Under 65 573 627

Non-Cancer 65+ 1,800 1,969

Total 3,111 3,403

Incremental Growth

Hospice Admissions 2011 to Year One 2011 to Year Two

Total 294 586

Projected

Market Shares 5.75% 9.00%

Admissions by HMC in Subdistrict 3E

Cancer Under 65 12 21

Cancer 65+ 30 52

Non-Cancer Under 65 33 56

Non-Cancer 65+ 104 177

Total 179 306

Average Length of Stay 40 52.1

Projected Patient Days 7,160 15,943

Average Daily Census 19.62 43.68


The applicant presents the expected distribution of projected patient

days by level of care provided reflecting HMC’s commitment to maintain

patients in their homes to the greatest extent possible. See the table

below.

Projection of Patient Days by Level of Care

Year One Year Two

Routine Home Care 6,630 14,763

Continuous Home Care 379 845

Inpatient Respite Care 129 287

General Inpatient Care 22 49

Total 7,160 15,943 Source: CON application #10142, page 109.

HMC states that it will be able to achieve its projected utilization without

any material impact on the existing hospice provider because it will serve

a number of hospice patients that will reduce the incremental need

shown in the Agency for Health Care Administration’s need methodology.

The applicant provides additional factors that support the conclusion

that the existing provider will not be adversely affected, including:

HMC intends to enter Subdistrict 3E with the same dedication to

meeting the broad needs of the community as it currently has in

Subdistrict 3B, which will result in an increasing the hospice

penetration rate. To the extent that the penetration rates are higher

than projected, there will be an even greater number of hospice

patients to be shared by the existing provider and HMC.


46

HMC will bring new programs and approaches to meeting the hospice

needs of Subdistrict 3E. The special needs populations the applicant

has targeted may choose hospice care in larger numbers, contributing

to the higher penetration rate.

HMC will provide services that are not currently adequately provided

by the existing Subdistrict 3E hospice provider. By doing this, HMC

services will offer local residents an alternative by increasing the

awareness and participation in the hospice programs.

VITAS Healthcare Corporation of Florida (CON #10144) provides a

summary of the Agency need calculation for Subdistrict 3E. The

applicant maintains that the Agency need for an additional hospice does

not indicate any current patients are not being served, but that the

planning area can support an additional provider with a number of

admissions sufficient to provide a high quality program without reducing

current admissions to existing hospices as a group. See the table below.

Agency for Health Care Administration Need Calculation

Subdistrict 3E Under 65

(Cancer diagnosis)

65+ (Cancer diagnosis)

Under 65 (non-cancer diagnosis)

65+ (non-cancer

diagnosis)

Total

Cornerstone Hospice Total** 431 1,208 226 2,386 4,251

Percentage Mix 10.1% 28.4% 5.3% 56.1% 100.0%

Cornerstone Hospice 3E Estimate 286 800 150 1,581 2,817

Projected Deaths 7/13-6/14 314 908 721 2,810 4,753

Statewide Use Rate 2011 0.934 0.960 0.226 0.681 0.658

Projected Need 7/13-6/14 293 872 163 1,913 3,241

Current Utilization 2011 286 800 150 1,581 2,817

Projected Hospice Need 7/13-6/14 293 872 163 1,913 3,241

Net Need 7 72 13 332 424 ** Also serves an adjacent service area. Therefore, Cornerstone Hospice admissions have been interpolated solely for

Subdistrict 3E by applying percent mix of admissions by age and disease status to total subdistrict admissions for

this hospice.


The applicant contends that there is a need for a second hospice in

Subdistrict 3E as residents currently do not have a choice of hospice

providers. Approval of the proposed program, VHCF asserts, will result

in choice for patients and healthy competition between VHCF and

Cornerstone.

VHCF indicates that Cornerstone Hospice & Palliative Care is well

established with deep roots and well-established referral relationships.

The applicant states that not every new hospice is successful against

entrenched existing providers citing disappointing start-ups including:

Odyssey in Subdistrict 3B, Regency in District 1, Compassionate Care in

Subdistrict 6B, Heartland in Subdistrict 4A and Catholic in District 10.

VHCF states that these hospice programs are not effective competitors.


47

The applicant indicates that an approved applicant must have the

resources and demonstrated ability to create a successful new hospice.

VHCF contends that there have only been two effective competitors with

admission volumes that meet or exceed the projections in the

applications—VITAS in Subdistrict 8B (licensed May 2008) and VITAS in

Subdistrict 4A (licensed May 2011). See the table below.

Projected and Actual Admissions in First Two Years of Operation

Florida Hospice Programs Hospice

Subdistrict

Projected Actual Difference

Yr 1 Yr 2 Q1-Q4* Q5-Q8 Yr 1 Yr 2

Hospice of Citrus County 3A 234 544 85 258 (149) (286)

Heartland 4A 156 276 106 95 (50) (181)

Catholic Hospice 10 457 495 119 318 (338) (177)

VHCF 8B 186 354 183 406 (3) 52

Haven/N. Central Florida

Hospice

4B

140

250

108

108

(32)

(142)

Regency 1 242 496 78 184 (164) (312)

Odyssey 3B 285 405 185 208 (100) (197)

Compassionate Care

Hospice

6B

275

415

148

NA

(127)

--

HCR Manor/Heartland 11 321 437 99 NA (222) --

VHCF 4A 162 297 302 NA 140 --

Hospice of Palm Beach

County

10

250

570

NA

NA

--

--

Memorial Flagler

Hospital/Florida Hospital

Hospice Care

7B

280

410

NA

NA

--

-- *It should be noted that the applicant began with the quarter after a hospice was licensed to estimate the

number of admissions for the first two years of operation.


VHCF contends that it is significant to know how quickly the approved

applicant will be licensed and in operation—the Agency should be

mindful how quickly the applicant it approves will actually offer services.

The applicant states that the average time from CON approval to

licensure for the two VHCF hospices was 34 days while Compassionate

Care Hospice delayed licensing for over 15 months in 6B. VHCF has

scheduled licensure in the month after it receives final approval—actual

experience shows that this goal can be achieved.

The applicant analyzed the unmet needs in Subdistrict 3E using the

Hospice Standard Analytical File (SAF) and the Denominator File, making

the necessary adjustments to restrict the analysis to the 65+ population

(constituting over 95 percent of the unmet need in the subdistrict).17

Based on this data, VHCF made the following findings on need:

17 The SAF and the Denominator File are both published annually by the Centers for Medicare and Medicaid Services. The full analysis is provided by the applicant in Tab 13 of CON application #10144.


48

Patients with non-cancer diagnoses in the subdistrict have a lower

Medicare hospice admission rate (49.93 percent) than the state

average (57.47 percent). This confirms the Agency data showing the

largest need is in the 65+ non-cancer subgroup.

Only 49.8 percent of Sumter County’s 2010 Medicare beneficiaries’

deaths were admitted to hospice care in 2010. This number is below

the subdistrict’s admission rate and far below Florida’s Medicare

hospice admission rate of 64.6 percent. While both counties are

underserved, the population is greater in Sumter County.

African-American patients in the subdistrict have a lower hospice

admission rate than the state average, with African-American

experiencing a 48.3 percent admission rate in 3E and a 52.5 percent

admission rate statewide.

Hispanic patients in the subdistrict have a hospice admission rate

very close to the state average for Hispanics. Hispanics do not appear

to be an underserved group in the subdistrict.

According to July 1, 2011 census data collected by AHCA, the existing

hospice in Subdistrict 3E served 30 percent of its total patients in

nursing homes or assisted living facilities. This percentage is lower

than the average Florida percentage of 42 percent, and illustrates the

need for a hospice experienced in providing care to patients in nursing

homes or assisted living facilities. On the same date VHCF hospices,

combined, were serving 46 percent of their patients in nursing homes

or assisted living facilities, demonstrating VHCF’s ability to serve

these patients.

VHCF states that for several decades there has been no competitive

pressure on Cornerstone to improve its outreach to underserved groups

or to increase its responsiveness to its patients. The applicant maintains

that approval of proposed program will create both choice and

competitive pressure—benefitting the residents of the subdistrict.

The applicant indicates that it will bring new resources for community

education and benefit the residents of Subdistrict 3E by raising the

admission rate. VHCF and VITAS state that it has developed programs

to better reach African-Americans and patients with non-cancer

diagnoses. The applicant also maintains that it has proven its ability to

reach patients in nursing homes—creating programs and training to

meet the needs of patients in these facilities. These underserved sub-

population groups fit within the specialized programs offered by VHCF

and will be served by the proposed program.


49

VHCF states that the initial office of the proposed program will be located

in the Leesburg, Florida area. The applicant chose this location based on

the functions of the office and on an analysis of population distribution,

the road network and the location of long-term care facilities. This office

will be able to efficiently serve the large number of deaths in Lake County

while also reaching underserved patients in Sumter County. The

applicant will open and staff an office in Sumter County by the end of the

first year of operations.

The applicant indicates that 55 percent of the subdistrict’s Medicare

patient deaths in calendar year 2010 received hospice services, well

below the state average of 64.6 percent for patients 65+. VHCF

maintains that not serving as many terminally ill elderly residents in a

hospice program increases the costs borne by the health care system.

The applicant asserts that it will reach out to underserved population

groups and increase market penetration as it has in other Florida

markets. VHCF contends that its contribution to increasing admission

rates in the subdistricts it currently serves illustrates its ability to

increase awareness of hospice and provide hospice care to the

community. See the table below.

Hospice Admission Rates in VHCF Subdistricts

Calendar Year 2005-2010 Subdistrict CY 2005 CY 2006 CY 2007 CY 2008 CY 2009 CY 2010

4A VITAS Opened in 2011

4B 53% 57% 61% 66% 70% 70%

7A 55% 58% 60% 63% 64% 67%

7B 51% 55% 60% 60% 63% 61%

7C 46% 52% 56% 58% 58% 58%

8B VITAS Opened in 2008 56% 62% 70%

9C 62% 67% 67% 70% 70% 72%

10 55% 55% 57% 56% 58% 58%

11 40% 41% 44% 46% 50% 53%

Total 51% 53% 56% 57% 60% 61% Source: CON application #10144, page 20.

VHCF maintains that statistics document a shortcoming of the existing

hospice to effectively reach the African-American community in the

subdistrict. One explanation for this may be the relatively small size of

this community in the subdistrict—the African-American age 65+

population in the subdistrict in 2010 was 3,550. VHCF asserts that it is

willing to make the special commitment to reach a small community

within the total elderly population.

VITAS works with many African-American professionals, religious and

civic organizations to increase African-American access to hospice care—

including working with Bethune-Cookman University’s nursing program

to support opportunities for end of life care education for advanced


50

nursing students. VITAS also created a community liaison position to

serve as a community educator and hospice advocate to promote

relationships with key members of their respective communities. The

applicant indicates that these positions are essential in furthering

VITAS’s commitment to bring quality hospice care to diverse and

underserved communities.

The applicant maintains that it does a better job of working with the

African-American community than Cornerstone Hospice and Hospice of

Marion County. VHCF supplied a summary of the percentage of

admissions it, Cornerstone Hospice and Hospice of Marion County

provided to African-American patients in 2010 and the percentage of

areas residents ages 65+ that were African-American. See the table

below.

Percent of African-American Residents and Hospice Patients by Provider

Calendar Year 2010 Hospice Hospice % Resident % Percent Difference

Cornerstone 4.60% 7.70% -40.3%

VHCF 10.06% 8.66% 16.1%

Hospice of Marion County 5.86% 5.64% 4.1% Source: CON application #10144, page 23.

Upon approval of this application, VHCF will develop an aggressive and

effective outreach program to the African-American community in both of

Subdistrict 3E’s counties. The outreach program will utilize the written

materials, community liaison positions and other techniques that have

proven effective in areas VHCF currently serves.

VHCF and VITAS have specialized programs, that have proved effective

elsewhere, for specific disease categories which will be implemented in

Subdistrict 3E including18:

Chronic Obstructive Pulmonary Disease (COPD)

Alzheimer’s

Heart Disease

Diabetes

Admission rates for non-cancer patients of all ages, especially non-cancer

patients 65+ are far below expectations. According to the applicant,

Agency for Health Care Administration data shows 78.3 percent of the

growth in demand in Subdistrict 3E is generated by non-cancer patients

65+. VHCF states that it has proven success with non-cancer patients.

18 The applicant provides sample educational material for specific disease categories in TAB 19.


51

The applicant maintains that it is programmatically superior in

educating the community and generating referrals of terminally ill non-

cancer patients with a long history of operational experience in serving

this group. See the table below.

Hospice Experience with Non-Cancer Patients

2009 2010 2011

Existing Subdistrict 3E providers 58.9% 63.3% 61.4%

VHCF Florida Hospices 67.9% 68.9% 69.4%

State of Florida 64.5% 65.3% 65.6% Source: CON application #10144, page 24.

The applicant analyzed the causes of death by studying the subdistrict

death rate with a focus on terminal rather than sudden causes and has

identified several disease categories that have need and are underserved.


Office of Vital Statistics--Death by Cause

Calendar Year 2008-2010 Subdistrict 3E

Cause

2008

Percent of Total

2009

Percent of Total

2010

Percent of Total

Cancer 838 19.4% 940 21.1% 897 19.6%

Diabetes 142 3.3% 120 2.7% 146 3.2%

Cardiovascular 1,086 25.2% 1,116 25.0% 1,161 25.3%

COPD/Respiratory 214 5.0% 200 4.5% 200 4.4%

Alzheimer 343 7.9% 324 7.3% 398 8.7%

Chronic Liver 42 1.0% 50 1.1% 47 1.0%

Pneumonia & Influenza 45 1.0% 41 0.9% 39 0.9%

Stroke 186 4.3% 191 4.3% 193 4.2%

Renal Failure 50 1.2% 59 1.3% 44 1.0%

HIV/AIDS 22 0.5% 15 0.3% 17 0.4%

Other 1,350 31.2% 1,408 31.5% 1,443 31.4%

Total 4,318 100.0% 4,464 100.0% 4,585 100.0% Source: CON application #10144, page 25.

VHCF cites that cardiovascular disease represents 25 percent of all

deaths in Subdistrict 3E—more than cancer’s 20 percent. The applicant

maintains that it has a proven history of providing quality care to

patients with cardiovascular disease and heart failure. VHCF states that

patients with cardiovascular disease require special hospice care that is

not being provided by Cornerstone, as attested in the excerpted letter

below:

“The resources for hospice in Lake County are currently very limited. The

one provider in Lake County has not been able to manage the needs of my

advanced heart failure patients…”

--Sita Price, Heart Failure Program Coordinator, ORMC,

Orlando Heart Institute.


52

The applicant states that it will develop programs identifying those with

heart disease, Alzheimer’s disease, stroke and pulmonary conditions. In

addition, VHCF will accept as a condition on CON application #10144

that at least 65 percent of patients admitted will have non-cancer

diagnoses.

VHCF notes that patients 65+ with non-cancer diagnoses are sometimes

in nursing homes when hospice services commence and that it has

successfully worked with nursing homes throughout Florida to provide

hospice services to its patients. According to July 1, 2011, census data

collected by the Agency for Health Care Administration, the existing

hospice in Subdistrict 3E served 30 percent of its total patients in

nursing homes or assisted living facilities, well below the state average of

42 percent. However, the applicant’s data is based on the Agency’s semi-

annual reports, which include one day snap shots, January 1 and July 1

of calendar years 2010 and 2011. The Department of Elder Affairs data

is based on annual totals which would be more definitive.

The applicant states that this shortfall in nursing home patients may

reflect a lack of outreach or it may reflect a perceived competitor to

nursing homes in the form of Cornerstone’s four hospice residences.

VHCF indicates that it can work effectively with nursing homes in the

Subdistrict.19

VHCF maintains that it is the best able applicant to establish a

successful hospice program in Subdistrict 3E. The applicant asserts that

it is committed to serving all patients, providing 19,900 days of charity

care in 2011. The applicant states that it has the experience,

management resources and financial resources to assure a rapid and

successful start-up in Subdistrict 3E.

VHCF provides the highest percentage of continuous care days of any

applicant, ensuring that patients are able to be treated where they

reside. See the table below.

Continuous Care Days Calendar Year 2010

Provider

Total Days

Continuous Care Days

Percent Continuous Care

Compassionate Care (Nationwide) 907,850 3,492 0.4%

Hospice of Marion County 147,293 1,706 1.2%

Harbor Light Hospice (Nationwide) 294,626 9 0.0%

VHCF (Statewide) 1,767,091 108,301 6.1% Source: CON application #10144, page 31.

19 The applicant includes examples of training documentation in Tab 20 of CON application #10144.


53

The applicant contends that of the competing applicants, only it has a

track record of successfully expanding its services to additional Florida

counties. VHCF gives several reasons why it is the applicant best

equipped to quickly establish a successful hospice program in

Subdistrict 3E, these include:

Compassionate Care Hospice waited 476 days to become licensed

after receiving final AHCA approval.

Compassionate Care Hospice’s admissions are running below

projections.

Hospice of Marion County is very similar to Cornerstone in its

approach to hospice services, thereby not much of an alternative.

Both Cornerstone and Hospice of Marion County provide little

continuous care and develop an extensive network of hospice houses.

Hospice of Marion County already markets its hospice residences to

residents in Lake and Sumter County.

Hospice of Marion County does not offer any community hospice

services or palliative care services that VHCF does not currently

provide.

Harbor Light Hospice has no experience in Florida or adjacent

states.20 As the focus of its organization is in the Midwest,

establishing a hospice in Florida is a major geographic and cultural

leap.

VHCF provides several factors why it has been more successful in

creating new hospice programs in Florida, including:

VHCF began providing hospice services in Florida more than 30 years

ago. It has well-known referral sources throughout the state with an

excellent reputation. VHCF’s quality and patient satisfaction is the

reason for its reputation.

Since it has a long history in Florida, VHCF understands the states

many ethnic, cultural and religious communities, how to connect with

these communities and how to adapt hospice service to their specific

needs and desires.

VHCF knows how to work closely with local community groups,

government agencies, colleges and charities and to quickly be

recognized as a contributing member of the local community.

20 Harbor Light Hospice does provide hospice services in Ellijay, Georgia; Dalton, Georgia; and Scottsboro, Alabama.


54

VITAS has created 26 new hospices since 2001—with the human,

financial and organizational resources as well as the experience to

quickly establish new programs to make them successful.

VITAS is widely recognized for its hospice leadership at the state and

national levels. Director level positions are held by VITAS

professionals at the Florida Hospice and Palliative Care Association

and the National Hospice and Palliative Care Organization.

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.

Each applicant is responding to published need for an additional

hospice program for the July 2011 planning horizon.

Each applicant discusses serving populations they believe to be

underserved.


(CON #10140) states that it is committed to meeting the needs of

all patients and their families in need of end-of-life care in Lake

and Sumter Counties. The applicant maintains that based upon

the Agency for Health Care Administration’s Florida Need

Projections for Hospice Programs, all age groups and all diagnoses

for hospice service in Hospice Service Area 3E are underserved. In

addition, Compassionate Care identified terminally-ill resident with

end stage cardiovascular disease as an underserved patient

population. The applicant indicates that its strategy and initial

plan for enhancing accessibility to hospice amongst all these

groups is provided in response to Question 1.

Harbor Light Hospice of Florida, Inc. (CON #10141) maintains

that it is committed to serving the entire population of Hospice

Service Area 3E, but specifically commits to serve the populations

with unmet needs. The applicant identified the following

populations as underserved:


55

Non-cancer patients under the age of 65 years

Non-cancer patients 65+

Hispanic/Latino community

The applicant notes that despite an increase in the number of

deaths in Hospice Service Area 3E, the number of deaths served by

the sole hospice provider has grown at a lower than expected rate

when compared to District 3 and the State of Florida. Harbor Light

contends that while the district and the State of Florida have made

significant strides in increasing the percentage of resident deaths

served by hospice, Hospice Service Area 3E has not. The applicant

concludes that this provides further evidence for the need for an

additional hospice provider in Hospice Service Area 3E.

Hospice of Marion County, Inc. (CON #10142) states that there

are significant unmet needs in Hospice Service Area 3E with

particular need demonstrated for: Hispanics, veterans, individuals

with chronic disease and pediatric patients (under age 21).

HMC indicates that through its proposed marketing and public

outreach efforts, access will improve throughout Hospice Service

Area 3E. The applicant will meet the unmet needs by providing

special programs that cater to the specified populations with

programs that include: special community education efforts,

clinical care protocols and bereavement services. The applicant

contends that hospice penetration rates can be raised to surpass

the state’s current penetration rate based upon its operational

history, experience and educational/outreach methods.

The applicant states that it will address the specific needs of

patients who are Hispanic by including bilingual patient and

educational materials. HMC will establish an office in the

Leesburg area initially, near a large and growing Hispanic

population.

HMC indicates that it has specialized qualifications to address the

needs of patients with chronic disease through it Chronic Disease

Self-Management Program that targets adults with long-term

health conditions such as arthritis, diabetes, cancer, chronic pain,

depression and others. The applicant will serve the lead facilitator

to initiate support workshops that focus on self-help for those with

these chronic diseases. HMC states that it also offers specialized

care for pediatric patients.


56

VITAS Healthcare Corporation of Florida (CON #10144) states

that it deserves this preference. The applicant indicates that it will

offer services to people of all ages, all disease groups and all

racial/ethnic groups. VHCF will serve patients regardless of where

in the subdistrict they reside, and in whatever place they call

home—nursing facility, hospital or private residence.

In addition, the applicant states that it has identified underserved

groups in Subdistrict 3E and has committed to serve those

populations. VHCF undertook detailed market research including

meetings with local providers and community leaders as well as

analysis of available data from the Agency and Medicare’s Hospice

Standard Analytical File to determine underserved groups and

areas. VHCF identified the following groups which are in need of

additional hospice services, all of these groups are predominately

in the 65+ population:

African-American patients

Non-cancer patients needing hospice services

Patients in nursing homes

Sumter County residents

VHCF states that the existing hospice has not adequately reached

out to these groups. The applicant maintains that it has

successfully increased hospice admissions from elderly black and

non-cancer groups in other Florida markets and understands what

is necessary in Subdistrict 3E. VHCF will commit to, and has

proven it is able to meet the current need. The applicant asserts

that given the opportunity, it will be successful in reaching and

meeting the needs of the underserved persons. However, VCHF

does not provide evidence from the local area that the statistical

appearance of lower utilization is an indicator of an underserved

group.

(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.


(CON #10140) intends to have contractual agreements with

nursing homes and hospitals, as well as other health care

providers to provide hospice inpatient care. The applicant states


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that by partnering with hospitals and nursing homes to provide

hospice inpatient care that it will fulfill its goal to expand

awareness and utilization of hospice.

The applicant notes that it has obtained letters of support from a

handful of assisted living facilities and nursing homes in the

Hospice Service Area. Compassionate Care states that it received

letters of support of CON application #10140 from several

cardiologists and neurologists who are on staff at the four local

acute care hospitals—Leesburg Regional Medical Center, The

Villages Regional Hospital, South Lake Hospital and Florida

Hospital Waterman. Compassionate Care also received a letter

from Steven Klein, CEO of Promises Hospital of Florida at The

Villages indicating his intent to enter into patient care

arrangements with the applicant upon CON approval. Superior

Residences of Clermont, an assisted living facility, expressed a

similar intent.

Compassionate Care contends that because existing hospitals in

the service area currently have contracts with the existing

provider, some were reluctant to provide letters of support to a new

provider until a CON is issued. The applicant is confident that it

will be able to enter into other contractual agreement to have

inpatient beds available at hospitals well-distributed in the service

area. Compassionate Care states that it will work cooperatively

with each hospital’s discharge planning department as a resource

for patients in need of hospice care.

Harbor Light Hospice of Florida, Inc. (CON #10141) proposes to

provide the inpatient care component of the hospice program

through contractual arrangements with existing health care

facilities. The applicant had one letter of interest included in CON

application #10141 from Osprey Point, a skilled nursing facility.

Hospice of Marion County, Inc. (CON #10142) proposes to

provide the inpatient care component of the proposed program

through contractual arrangements with existing health care

facilities, including acute care hospitals and skilled nursing

facilities. The applicant maintains that negotiations for additional

contracts with hospitals and nursing homes are ongoing to ensure

the widest network.


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The applicant states that it has been established in adjoining

Hospice Service Area 3B, Marion County, and has four hospice

houses there—Lake and Sumter residents will also be able to

choose from one of HMC’s already established hospice houses.

The applicant indicates that Tuscany House is already utilized by

some Subdistrict 3E residents.

HMC cites a letter of intent to contract for inpatient beds provided

by Florida Hospital Waterman once implementation of the

proposed program begins. The letter in included in CON

application #10142.

The reviewer notes that the applicant states the following condition

upon approval of CON application #10142, “to establish a

dedicated hospice inpatient unit in a hospital, skilled nursing

facility or freestanding hospice house once an average daily census

level of 150 has been attained for a six month period.”


that it deserves this preference. The applicant indicates that it

prefers to have contractual agreements with nursing homes and

hospitals to meet patient needs in Subdistrict 3E. VHCF

maintains that by partnering with hospitals and nursing homes to

provide hospice inpatient care, it will fulfill its goal to expand

awareness of and utilization of hospice. VITAS partners with both

non-profit and for-profit facilities in bringing hospices services to

the local communities it serves. VITAS operates 34 hospice

inpatient units across the country.

The applicant indicates that its agreements are not limited to just

inpatient facilities such as skilled nursing facilities and hospitals.

Some examples of the different types of contractual agreements

include:

Ambulance

Durable medical equipment

Inpatient respite care

Radiological

Therapy

Home health

Infusion therapy

Laboratory


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VHCF is seeking to establish a new hospice program with no plans

to establish its own inpatient unit in 3E in the foreseeable future.

Upon CON approval, the applicant states that it will establish

inpatient agreements within the subdistrict. VHCF indicates that

preliminary discussions with Edgewater at Waterman Village and

Lady Lake Specialty Care Center have shown a willingness to enter

into contractual agreements with the applicant pending CON

approval and upon licensure. Letters of interest from these

facilities were included in CON application #10144.

(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.


(CON #10140) maintains that it is committed to serving all

patients including those who do not have primary caregivers at

home, the homeless and patients with AIDS in Subdistrict 3E as

evidenced by its history of serving these patient populations in its

existing markets.

In the case that a patient is not able to care for him/herself and

has no caregiver support group, Compassionate Care may

recommend placement in an assisted living facility or nursing

home in which it will be able to provide residential care.

Compassionate Care social workers will assist patients without

financial resources to obtain residential care in a hospice unit

within an assisted living facility or nursing home, as determined by

their medical condition. The applicant proposes to establish

relationships with area nursing homes and assisted living facilities

as the need arises.

In addition to its commitment to serving patients either without

caregivers at home, with compromised caregivers and AIDS

patients, Compassionate Care will service homeless individuals. If

a patient in need of hospice care is homeless, the applicant will

place the patient in an inpatient unit and assist him/her with

applying for Medicaid. Once the patient qualifies, he/she will be

placed in a long-term care environment where the patient can

begin or continue hospice care.


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Harbor Light Hospice of Florida, Inc. (CON #10141) states that

it will serve patients who do not have primary caregivers at home,

the homeless and patients with AIDS. At admission, patients are

given an initial assessment from a team of professionals with

factors such as the current clinical condition of the patient, safety

of the environment, educational needs and current state of

finances.

The applicant maintains that when a primary caregiver is not

continually present with a patient, the patient’s environment is

always discussed with contingency plans for when/if the patients

becomes compromised at a bi-weekly conference meeting with the

professional team. The Harbor Light Team is proactive in helping

patients through all transition, including moving to or developing a

safe environment when caregiver breakdown is detected.

Harbor Light indicates that if a patient does not have a caregiver, a

social worker immediately develops a plan of care to provide for

care and present options to the patient, including providing

assistance in securing a bed in a facility. Upon assessment, the

social worker assists family in accessing appropriate community

resources.

Hospice of Marion County, Inc. (CON #10142) provides service

to everyone who makes an inquiry, beginning with information,

education, referral and counseling. The applicant states that it will

admit all patients who qualify for hospice care within its licensed

service area, including homeless persons, persons without primary

caregivers and persons with HIV/AIDS.


that it deserves this preference. The applicant asserts that it is

committed to serving all residents, including the homeless,

utilizing all community and VITAS resources as necessary to

assure a safe and comfortable environment. VHCF maintains that

terminally ill patients with no at home support will receive

increased attention from the hospice staff. The applicant states

that every effort will be made to develop a caregiver network from

among neighbors, nearby relatives and friends, church members

and hospice volunteers who will be capable of providing the

necessary amount of supervision, assistance and companionship

to the patient within the patient’s or caregiver’s home.


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Patients living alone with the ability to care for him or herself for

the most part, will be assisted by the applicant in developing a

network of caregivers to assist the patient or recommend that

qualified adult sitter services be obtained should that not pose a

financial hardship. VHCF may provide patients or family members

with cell phones for 24-access and communication to those who

may have none available. Where appropriate, the applicant will

provide continuous care to allow the patient to remain at home.

VHCF notes the WellFlorida Councils’ identification of an

increasing population of homeless residents in the southern part of

Lake County. The applicant states that it is committed to serving

the growing homeless population in Lake County. In cases where

the patient is homeless, VHCF may assist patients to find

placement in an assisted living facility or nursing home—

caseworkers will assist patients in applying for available funding

for room and board. The applicant proposes to establish

relationships with area nursing homes and assisted living facilities

to serve patients in this situation as the need arises.21

The applicant notes that HIV and AIDS deaths do not account for a

significant portion of deaths in Subdistrict 3E—15 AIDS related

deaths in 2009 and 17 in 2010. VHCF does maintain that it is

aware of the unique need of patients with this diagnosis. The

applicant is committed to ensuring terminally-ill individuals with

HIV have access to hospice services—including specialized training

for staff and volunteers.

(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 3E consists of only two counties, Lake and

Sumter. This criterion is not applicable to this review.

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


(CON #10140) states that it offers a host of special programs and

services that are not specifically covered by private insurance,

21 A copy of sample contracts to be used with nursing homes and assisted living facilities for this purpose are included in TAB 17 of CON application #10144.


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Medicare or Medicaid. The applicant presents a list of ‘Non-Core

Services’ it will provide as a condition of approval of CON

application #10140, including:

Pathways to Compassion, a palliative care program

Cardiac Connections

Promise Program, to meet the requirements of the needy

population

Veterans Outreach

Complementary Care Program which includes: massage

therapy, music therapy, energetic care, sacred spaces, guided

imagery, reminiscence therapy, pet therapy, aromatherapy,

reflexology and hypnotherapy

Transitions, a community service program

Jewish Hospice Program

Hispanic Hospice Program

Compassionate Care 4 Kids

Life Enhancement Specialists, provides recreational activities

for socially isolated patients

First Night at Home

Community Outreach

Volunteer Services

Bereavement Services

Rainbows, a bereavement support program for children

Comfort Corners, decorates designated areas in long-term care

facilities

Harbor Light Hospice of Florida, Inc. (CON #10141) maintains

that it currently provides required patient care services not

specifically reimbursed by private insurance, Medicaid or Medicare

in its existing hospice operations and will provide similar

supportive services as needed in this proposed hospice program.

These services will include, but are not limited to, pet therapy,

massage therapy, aroma therapies, dialysis, palliative radiation

and palliative chemotherapy. The applicant indicates that these

services will be provided through the trained employees/volunteers

and through contractual agreements for services requiring a

hospital environment setting.

Hospice of Marion County, Inc. (CON #10142) states that it

currently and will continue to provide a broad range of services

that are not covered by private insurance, Medicaid or Medicare.

Specific non-covered services provided include:


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Bereavement and grief support programs

Integrative/expressive therapies such as massage therapy, pet

therapy, music appreciation and Reiki.22

Supportive counseling

Volunteers to provide respite for caregivers at home, assistance

with errands and light homemaking tasks

Services to persons who have exhausted their insurance benefit

Recruitment, training and use of volunteers to augment HMC’s

capabilities

Veteran recognition events

Community education

Employee programs


that it deserves this preference. The applicant asserts that VITAS

has made a strong commitment in this regard from its beginning

days when all patients were care for solely depending on donations

and volunteers. VITAS states that it provides at least one percent

of revenues in charity care. For fiscal year 2011, this amount

exceeded $9.9 million while charity care amount for Florida

hospices exceeded $4.5 million.

VHCF indicates that it will provide the following non-core services

as a condition of approval of CON application #10144:

VHCF will meet exceed the statutory requirement in 400.60501,

Florida Statutes. Seventy percent or more of patients who

report severe pain (seven to 10 on the World Health

Organization pain scale) will report a reduction to five or less on

the pain scale within 48 hours after admission.

A VHCF staff member or volunteer will attend at least 90

percent of all deaths to ensure patients do not die alone.

VHCF will achieve an overall patient satisfaction score of 90

percent or above on the patient’s family’s evaluation of care

while under the care of VITAS.

VHCF will achieve an overall Registered Nurse satisfaction score

of 90 percent or above on patient’s family satisfaction with the

VHCF nurse while under the care of VITAS.

22 According to Reiki.org, Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. “It is administered by ‘laying on hands’ and is based on the idea that an unseen ‘life force energy’ flows through us and is what causes us to be alive.”


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VHCF will implement a Pet Therapy program to begin

immediately. PetPals is a program where screened dogs visit

shut-ins, nursing homes, assisted living facilities, adult day

care center and Alzheimer patients.

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.


(CON #10140): As reflected in Schedule 6A of the

application, the following is the proposed Subdistrict 3E

staffing for each of the first two years of operation.

Compassionate Care Proposed Staffing for Subdistrict 3E

April 2013-March 2015 First Two Years of Operation

Position

Average Number of FTEs Year One

Average Number of FTEs Year Two

Administrator 1.0 1.0

Professional Relations Coordinator 1.0 1.0

Secretary 1.0 2.0

Community Liaison 0.5 1.0

Clinical Coordinator 1.0 1.0

Medical Director 0.2 0.5

Registered Nurses 2.0 4.5

Per Diem Registered Nurses 0.3 1.0

LPN 0.0 1.0

Per Diem LPN 0.0 0.5

Nurses’ Aides 6.0 14.0

Nurse Practitioner 1.0 1.0

Per Diem Nurses’ Aides 0.4 1.6

Continuous Care Per Diem LPN 0.6 1.81

Continuous Care Per Diem Aide 0.6 1.81

Life Enhancement Specialist 0.2 1.0

Music Therapist 0.2 0.5

Massage Therapist 0.2 0.5

Dietary Services 0.2 0.5

Social Worker 1.0 2.0

Volunteer Coordinator 0.5 1.0

Chaplain 0.5 1.0

Total 18.4 40.22 Source: CON application #10140, page 87.


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The applicant indicates that staffing is based upon the

anticipated direct nursing and care staff to be utilized in the

delivery of hospice services and the direct support staff

required. Compassionate Care states that clinical staff

includes one clinical coordinator and one nurse practitioner

who will be dedicated to the Cardiac Connections Program as

well as specially designated continuous care LPNs and

nurses’ aides. Compassionate Care maintains that

volunteers will also be recruited enthusiastically consistent

with the volunteer services program.

Harbor Light Hospice of Florida, Inc. (CON #10141): As

reflected in Schedule 6A of the application, the following is

the proposed Subdistrict 3E staffing for each of the first two

years of operation.

Harbor Light Proposed Staffing for Subdistrict 3E

Calendar Years 2013 and 2014 First Two Years of Operation

Position



Marketing 1.2 2.0

Executive Director 1.0 1.0

Supervisor 0.3 1.2

Office 0.7 1.0

Patient Care Coordinator 0.7 1.0


R.N.’s 1.1 4.7

L.P.N.’s 0.4 1.7

HHAs 1.1 4.7

Bereavement Coordinator/Chaplain 0.3 1.2

MSW/Volunteer Coordinator 0.6 2.4

Total 7.4* 20.9* *These numbers should be 7.42 and 21.0, respectively.

Source: CON application #10141, Schedule 6A, page 130.

Harbor Light states that it will routinely provide

substantially all core services directly by hospice employees.

The applicant indicates that its interdisciplinary team

consists of a nurse, certified nursing assistant, volunteer,

chaplain, social worker and medical director. The reviewer

notes that there were no FTE allocations for a social worker

or certified nursing assistant on the applicant’s Schedule 6A.

The applicant indicates that extra attention from the entire

team promotes quality of life and dignity throughout the last

moments of life. In addition, Harbor Light states that it will

call in, as needed, specialists such as a dietician or a

therapist to meet the specialized needs of a dying person.


66

Harbor Light maintains that it provides all hospice

diagnosis-related medications, including all pain control and

symptom control measures. It will provide medical

equipment and supplies helpful to controlling symptoms,

including equipment that would prevent skin breakdowns.

The applicant contends that without hospice services, this

would have to be paid for by the family.

Hospice of Marion County, Inc. (CON #10142): As

reflected in Schedule 6A of the application, the following is

the proposed Subdistrict 3E staffing for each of the first two

years of operation:

Hospice of Marion County Proposed Staffing

Subdistrict 3E Calendar Years 2013 and 2014 First Two Years of Operation

Position



Medical Records Clerk 0.5 1.0

Volunteer Services ---- 0.5

All Other Administration 2.75 3.5

Physicians 0.25 0.35


R.N.’s 4.5 6.0

L.P.N.’s 1.5 1.5

Hospice Aides 1.5 3.0

Pharmacy ---- 0.5

Dietician 0.2 0.2


Chaplain 0.5 1.0

Bereavement Counselors 0.25 0.5

Total 13.7 20.55 Source: CON application #10142, Schedule 6A.

The applicant maintains that the proposed staffing has been

developed based on its operational experience. HMC states

that it will provide certain support and billing services for the

proposed program from its Ocala offices.

HMC states that volunteers do not appear in the above

schedule but that it anticipates recruiting, training and

using volunteer staff at approximately the same proportion

as it does in its Marion operation relative to admissions.

Currently, the applicant utilizes 600 individual volunteers

including 25 whom already reside in Lake/Sumter County.

The volunteer’s services range from patient support activities

to administrative/clerical activities to outreach activities.


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VITAS Healthcare Corporation of Florida (CON #10144):

As reflected in Schedule 6A of the application, the following

is the proposed Subdistrict 3E staffing for each of the first

two years of operation:

VHCF Proposed Staffing for Subdistrict 3E

October 2012-September 2014 First Two Years of Operation

Position



General Manager/Administrator 1.00 1.00

Admissions/Hospice

Reps/Community Liaison

3.46

4.50

Bereavement Manager 0.71 1.00

Business Manager 0.83 1.00

PC Secretary 1.00 1.50

Receptionist 0.75 2.00

Medical Director/Physician 0.45 0.93

Team Director (RN) 1.25 2.25

Continuous Care Manager 0.00 0.75

RNs 3.06 6.74

LPN/Aides 7.65 24.15

On-Call Representatives 1.58 2.00


Chaplain 1.00 1.13

Total 23.96* 50.78 *This number should be 23.95.


The applicant indicates that some staffing positions and

support functions will be provided via overhead allocation

from existing VHCF operations. Volunteer staff hours are

expected to equate to a minimum of five percent employee

time. Additionally, dietary counseling will be a key part of

VHCF’s service.23

(b) Expected sources of patient referrals.


(CON #10140) believes due to the area’s tremendous need

for hospice services and the highest quality of care provided

by the applicant, attracting patients will not be difficult.

Referrals will come from area physicians, hospitals, nursing

homes, health care providers, family members and the

patients themselves. The applicant notes the many letters of

support for the proposed program from area physicians,

assisted living facilities, nursing homes, hospitals, other

community organizations and residents. Compassionate

23 Dietary services expense are included under the “homecare ancillary” line item on Schedule 8a of the financial schedules within TAB 2 of CON application #10144.


68

Care contends that these letters both constitute groups likely

to provide referrals as well as showing the eagerness of the

community for the applicant to initiate services.

Harbor Light Hospice of Florida, Inc. (CON #10141)

indicates that in a hospice, a client base is built through

providing superior levels of service which results in earning

the trust of those who are in a position to recommend

hospice service to patients and families. Harbor Light will

develop a reputation for excellence in care thereby gaining

the trust and admiration of professionals who refer patients

to the program.

The applicant states that it currently operates 19 programs

in eight states and has successfully developed and

maintained strong relationships with referral source in

support of each of these programs. In preparation for CON

application #10141, Harbor Light has been engaged in

extensive ground work to enhance its understanding of the

local area and introduce itself to the Lake/Sumter medical

community and the spectrum of potential referral sources.

The applicant states it has had a positive reception. Harbor

Light is fully confident in its ability to integrate into the area

and succeed by devoting all necessary resources to

establishing contacts and effectively conveying its history,

experience and commitment to quality.

In addition, Harbor Light Chairman Frank Rosenbaum

included a letter of intent to purchase an existing, well-

established home health agency whose operations

encompass Lake and Sumter Counties and serve a large

volume of patients in these counties. The applicant

contends that while no direct affiliation will exist between the

home health agency and Harbor Light, Mr. Rosenbaum’s

ownership position in the home health entity will bring with

it the immediate substantial benefit of established

relationships with physicians groups, hospitals, long-term

care and rehabilitation interests in Service Area 3E.

Hospice of Marion County, Inc. (CON #10142) provides a

list of sources it will target for hospice referrals, including:

Physicians

Hospital discharge planners

Social workers


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Nursing facilities

Assisted living facilities

Home health agencies

Group homes

Community social service agencies

Churches

Veterans groups

The applicant notes that the health care providers and

organizations that wrote letters of support for CON

application #10142 are indicative of the potential to gain

referrals from a variety of sources.

HMC indicates that it will conduct a variety of marketing

activities to let the community know of its presence as a

hospice provider in the district and has reserved a

considerable portion of the funding for the proposed project

for community outreach initiatives. In addition, the

applicant asserts that it recognizes the significant Hispanic

and Veterans communities within Hospice Service Area 3E

and will provide special programs that cater to the

populations. These programs will include special community

education efforts, clinical care protocols and bereavement

services for families in order to increase participation for

groups traditionally underrepresented.

VITAS Healthcare Corporation of Florida (CON #10144)

maintains that it knows how to enter a community with

established hospices and develop referral services based on

VITAS’ 26 successful hospice start-ups since 2001.

Referrals will come from area physicians, hospitals, clergy,

social service agencies, disease advocacy groups, nursing

homes, other health care providers, family members and

patients themselves. The applicant points to the letters of

support gathered for CON application #10144 in Subdistrict

3E and areas VHCF already serves. VHCF expects that its

reputation with groups and individuals in other service areas

will open doors with their counterparts in Subdistrict 3E.

In addition, the applicant will develop outreach programs

and services geared toward Subdistrict 3E referral sources.


70

The programs will enhance education about hospice services

and VHCF’s mission. The program also has budgeted

positions for community liaison personnel to work with the

African-American community and with groups working with

patients with non-cancer diagnoses.

VHCF points to its success in Subdistricts 4A and 8B and

expects referrals to the proposed program to be in addition to

referrals to the existing hospice in the subdistrict.

(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.


(CON #10140): The following table shows the projected

payer source for admissions by year for the proposed

program.

Expected Admissions by Payer Type

For Compassionate Care Hospice of Lake and Sumter, Inc. Service Area 3E

Payer Source Year One Year Two

Medicare 147 344

Medicaid 5 11

Charity 2 5

Insurance 3 6

Total 157 366


The applicant indicates that it does not expect to collect any

funds on the patients it treats during the first three months

of operation (representing 370 days of care), between

licensure and certification dates.

Harbor Light Hospice of Florida, Inc. (CON #10141): The

following table shows the projected payer source for

admissions by year for the proposed program.

Harbor Light Hospice of Florida, Inc. Projected Admissions by Payer Type Year One and Year Two of Operation

Medicaid

Medicare

Commercial/ Charity/ Other

Total

Year One 3 67 3 73

Year Two 8 188 8 204 Source: CON application #10141, page 69.


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Hospice of Marion County, Inc. (CON #10142): The

following table shows the projected payer source for patient

days by year for the proposed program.

Hospice of Marion County, Inc.

Projected Patient Days by Payer Type Year One and Year Two of Operation

Medicare

Medicaid

3rd Party Insurance

Self-Pay/ Other

Total

Year 1 6,437 408 215 100 7,160

Year 2 14,332 909 478 223 15,943

% of Total 89.9% 5.7% 3.0% 1.4% 100% Source: CON application #10142, page 130.

The applicant did not provide the projected number of

admissions by payer type.

VITAS Healthcare Corporation of Florida (CON #10144):

The following table shows the projected payer source for

admissions by year for the proposed program.

Projected Admissions by Payer

VITAS Healthcare Corporation of Florida Subdistrict 3E

Payer Type Year One Year Two

Medicare 197 391

Medicaid 10 19

Indigent 3 5

Private Insurance/Self-pay/ Other 4 8

Total 214 423


The applicant notes that the forecasted admissions were not

done by payer. However, patient days were projected by

payer and using patient day’s percentage of total provided a

reasonable forecast of admissions by payer.

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

illness, for the first two years of operation.


(CON #10140) provides the following summary table of

expected admissions by type.


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Projected number of Admissions by Diagnosis

For Compassionate Care Hospice of Lake and Sumter, Inc. Service Area 3E

Diagnosis Year One Year Two

Cancer 50 92

Cardiac 55 165

Respiratory 20 35

Renal Failure 10 20

HIV/AIDS 2 4

Other 20 50

Total 157 366 Source: CON application #10140, page 89.


indicates that it expects that the patients of the proposed

program will be similar to that of its national experience.


Harbor Light Hospice of Florida, Inc.

Projected Admissions by Type of Terminal Illness Years One and Year Two of Operation

Cancer CHF COPD Renal Other Total

Year 1 22 9 7 1 34 73

Year 2 61 27 18 4 94 204 Source: CON application #10141, page 69.

Hospice of Marion County, Inc. (CON #10142) provides

the following summary table of expected admissions by type.

Hospice of Marion County, Inc. Projected Admissions by Type

Years One and Two of Operation Year One

Hospice Admissions Year Two

Hospice Admissions

Under 65 65+ Total Under 65 65+ Total

Cancer 12 30 42 21 52 73

Other 33 104 137 56 177 233

Total 45 134 179 77 229 306 Source: CON application #10142, page 130.


provides the projected number of admissions by terminal

illness for the first two years of operation of the proposed

program. The applicant notes that one of its conditions

upon approval is that at least 65 percent of admissions will

be patients with non-cancer diagnoses. See the table below.


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Projected Number of Admissions by Diagnosis

VITAS Healthcare Corporation of Florida Service Area 3E

Disease Year One Year Two

Cancer 66 131

HIV/AIDS 2 4

Respiratory 17 34

Cardiac 27 54

Alzheimer/Cerebral

Degeneration

45 88

Cerebrovascular/Stroke 12 24

Other 45 88

Total 214 423 Source: CON application #10144, page 79.

(e) Projected number of admissions, by two age groups,

under 65 and 65 or older, for the first two years of operation. Compassionate Care Hospice of Lake and Sumter, Inc.

(CON #10140) provides the following table for the projected

number of admissions by age cohort.

Projected Admissions by Age Group

Compassionate Care Hospice of Lake and Sumter, Inc. Subdistrict 3E

Age Group Year One Admissions Year Two Admissions

Under 65 16 37

Over 65 141 329 Source: CON application #10140, page 90.


provides the following table for the projected number of

admissions by age cohort.

Harbor Light Hospice of Florida, Inc. Projected Admissions by Age Groups Years One and Year Two of Operation

Under 65 Over 65 Total

Year One 7 66 73

Year Two 20 184 204 Source: CON application #10141, page 70.

Hospice of Marion County, Inc. (CON #10142) provides

the following table for the projected number of admissions by

age cohort.


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Hospice of Marion County, Inc. Projected Admissions by Type

Years One and Two of Operation Year One

Hospice Admissions Year Two

Hospice Admissions

Under 65 65+ Total Under 65 65+ Total

Cancer 12 30 42 21 52 73

Other 33 104 137 56 177 233

Total 45 134 179 77 229 306 Source: CON application #10142, page 130.


provides the following table for the projected number of

admissions by age cohort.

Projected Admissions by Age Group

VITAS Healthcare Corporation of Florida Subdistrict 3E

Age Group Year One Admissions Year Two Admissions

Under 65 30 60

Over 65 184 363 Source: CON application #10144, page 79.

The applicant states that the reliability of its volume

projections in CON application #10144 is supported by

actual experience elsewhere in Florida. VHCF asserts that

its projections are conservative and represent minimum

expectations allowing for continued growth in admissions by

the existing hospice.

VHCF maintains that it would be unfortunate for the Agency

to reward applicants that project the largest number of

admissions. The applicant notes that most new hospice

program applicants fall well short of its application

projections. VHCF states that it is glad to serve as many

patients as it can, preferring to under promise and over

deliver in utilization projections. The applicant hopes it will

not be penalized for taking this approach.

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


(CON #10140) states that core services, including physician

services, nursing services, social work services,

pastoral/counseling and dietary counseling will be provided

for by its staff and volunteers. The applicant indicates that


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it will contract for certain services as needed by the patients

including: durable medical equipment, medical supplies,

pharmaceuticals, physical therapy, speech therapy and

occupational therapy. Non-core services to be provided by

Compassionate Care staff versus contract include massage

therapy, music therapy, energetic care, sacred spaces,

guided imagery, reminiscence therapy, pet therapy,

aromatherapy, reflexology, hypnotherapy, life enhancement

services and homemaker services.

Harbor Light Hospice of Florida, Inc. (CON #10141) states

that it will routinely provide substantially all core services

directly by hospice employees including Medicare-covered

hospice services and bereavement counseling. The applicant

provides a definition of duties for each member of its

interdisciplinary team:

The registered nurse focuses much expertise on pain

control and symptom management with the dying process

The medical director collaborates with the

interdisciplinary team to ensure that medical admission

prognostic criteria are met as well as the overall

responsibility for the interdisciplinary group ensuring

that all areas consistently meet patient and family needs

The social worker performs the role of a counselor with

the dying process of the resident, the residents’ family

and extended family

The Chaplain’s role is to establish or reconnect the

resident with his or her own religious roots.

The certified nursing assistant can spend extra time

assisting the patient with the activities of daily living,

writing notes to friends and escorting residents on walks

The volunteer can be a special friend, taking time to talk

to or to read to the resident

The applicant indicates that extra attention from the entire

team promotes quality of life and dignity throughout the last

moments of life. In addition, Harbor Light states that it will

call in, as needed, specialists such as a dietician or a

therapist to meet the specialized needs of a dying person.


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Harbor Light maintains that it provides all hospice

diagnosis-related medications, including all pain control and

symptom control measures. It will provide medical

equipment and supplies helpful to controlling symptoms,

including equipment that would prevent skin breakdowns.

The applicant contends that without hospice services, this

would have to be paid for by the family.

Hospice of Marion County, Inc. (CON #10142) states that

it will provide all of its core services directly by hospice staff

and volunteers, including:

Nursing services

Social work services

Spiritual services

Dietary counseling

Bereavement counseling services

Home health aides

Pharmacy services

Supplies and durable medical equipment

Homemaker and chore services

Physician services

Infusion therapy

Additional services may be provided through contractual

arrangement, including:

Physical, occupational and speech therapy

Patient transportation services

Additional physician services

The applicant indicates that other services that are needed

on an occasional basis, such as daycare, handyman services,

alternative therapies or funeral ceremonies may be provided

directly—if the requisite skill are available among the

staff/volunteers—or may be purchased on an as needed

basis from reputable providers.


states that core services, including physician services,

nursing services, social work services, pastoral counseling

and dietary counseling will be provided by the applicant’s

staff and volunteers. VHCF will contract for other services

as needed by the patients.


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The applicant anticipates having employees provide all

services with the exception of durable medical

equipment/supplies and pharmacy services. VHCF does

note that from time to time, there may be a need for

supplemental staff engaged in certain functions such as

physical therapy, speech-language, pathology, massage

therapy and occupational therapy. The applicant maintains

that establishment of managed care contracts, development

of per diem contracts and use of the Vx information

technology system within Subdistrict 3E will be easily

accomplished due to VHCF’s already licensed programs in

Florida.

(g) Proposed arrangements for providing inpatient care.


(CON #10140) states that its intent is to have contractual

arrangements with nursing homes and hospitals designed to

meet patient needs in Hospice Service Area 3E. The

applicant maintains that this is the most cost-efficient

alternative as the inpatient and respite need of the patients

can be easily met by existing hospital and nursing home

facilities. Compassionate Care anticipates 69 inpatient

hospice days for year one of operation and 210 in year two.

The applicant cites the letter of support by Promise Hospital

of Florida at The Villages indicating its intent to enter into

patient care arrangements with Compassionate Care upon

approval. Harbor Light Hospice of Florida, Inc. (CON #10141)

proposes to provide the inpatient care component of the

hospice program through contractual arrangements with

existing health care facilities. The applicant states that

Osprey Point Nursing Center is interested in and agreeable

to developing a contract with Harbor Light upon approval.

The letter was included in CON application #10141.

Hospice of Marion County, Inc. (CON #10142) proposes to

provide the inpatient care component of the proposed

program through contractual arrangements with existing

health care facilities, including acute care hospitals and

skilled nursing facilities. The applicant maintains that

negotiations for additional contracts with hospitals and

nursing homes are ongoing to ensure the widest network.


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A sample agreement is provided in Attachment AC in CON

application #10142.

HMC cites a letter of intent to contract for inpatient beds

provided by Florida Hospital Waterman once implementation

of the proposed program begins. The letter is included in

CON application #10142.

The applicant states that it does not propose to construct a

freestanding inpatient hospice facility in Subdistrict 3E at

this time. However, HMC contends that residents will have

access to Tuscany house, as they do now, which borders

Sumter County and is proximal to Lake County.

The reviewer notes that the applicant states the following

condition upon approval of CON application #10142, “to

establish a dedicated hospice inpatient unit in a hospital,

skilled nursing facility or freestanding hospice house once an

average daily census level of 150 has been attained for a six

month period.”


states that it has no plans to establish its own inpatient unit

in 3E in the foreseeable future. The inpatient and respite

need of these patients will be met by existing hospital and

nursing home facilities. The applicant states it will establish

inpatient agreements within the subdistrict upon CON

approval of application #10144. VHCF points to its

numerous inpatient agreements throughout Florida. The

applicant states that it is experienced in identifying the

appropriate facilities to help deliver hospice services

effectively and efficiently to patients and families. VHCF

indicates that The Edgewater at Waterman Village and Lady

Lake Specialty Care have shown a willingness to enter into

contractual agreements.

(h) Proposed number of inpatient beds that will be located in

a freestanding inpatient facility, in hospitals, and in nursing homes.


(CON #10140) indicates that it will not construct beds and

will be contracting for existing beds on an as needed basis.


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The applicant asserts that it will develop relationships with

existing providers to utilize existing infrastructure to provide

the residential and inpatient component of hospice care.

The applicant anticipates 69 inpatient hospice days for year

one of operation and 210 in year two.


that it will arrange for the provision of inpatient care through

contractual arrangements with hospitals, nursing homes

and other setting throughout Hospice Service Area 3E.

Hospice of Marion County, Inc. (CON #10142) indicates

that this is not applicable as it will contract for inpatient

beds with existing providers in Subdistrict 3. The reviewer

notes that the applicant states the following condition upon

approval of CON application #10142, “to establish a

dedicated hospice inpatient unit in a hospital, skilled

nursing facility or freestanding hospice house once an

average daily census level of 150 has been attained for a six

month period.”


states that the total number of inpatient days projected in

year two of the proposed program is 821. The applicant

indicates that it will contract for more beds than projected to

provide services conveniently for patients and to handle

census fluctuations.

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


(CON #10140) maintains that one or more of the following

clinical criteria should be present for a patient to be

considered appropriate for admission to general inpatient

care:


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Pain:

o Investigation to define appropriate treatment modality

o Active treatment to control pain, which may include

change in medication and/or the routes of

administration

o Titration of medications that cannot be done safely at

home

o Need for advanced technology for analgesic

administration, i.e., IV narcotics

Other Symptoms:

o Death is imminent and care requires ongoing and

frequent skilled nursing intervention

o Symptoms fail to yield to home management or

furnishing the needed care at home is no longer

feasible

o Severe anorexia/and or inability to swallow

necessitating alternative nutritional support

o Fluctuating/deteriorating mental status necessitating

titration of medications, change in environment or

consultation and intervention by psychologist or

psychiatrist.

o Severe shortness of breath or respiratory distress;

intractable nausea or vomiting; open lesions requiring

frequent professional care; unstable or multiple

pathological fractures; other complicated care that

cannot be provided in the home setting

o Need for continued close monitoring of unstable

recurring medical conditions, i.e. hemorrhage, severe

anemia, severe hypertension, unstable diabetes,

recurrent seizures, etc.

Psychosocial Pathology: evaluation of disturbed mental

status; depression, anxiety in the extreme; and perception

and/or understanding that responds more positively in a

comprehensive care setting that is reassuring, safe

and/or therapeutic.


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The applicant indicates that similar criteria are employed for

continued inpatient care. Compassionate Care employs

admission criteria relative to respite care consistent with

that modality of treatment.

To assure continuity of care between home and the inpatient

setting, the applicant states that a specific policy focused on

communication among team members, hospital staff,

physicians and others are used. Compassionate Care states

that this policy assures that there are no gaps in services,

treatment or patient needs.


indicates that it will admit patients to an inpatient bed for

the following reasons:

Short-term inpatient care for pain control

Symptom management

Respite services

The applicant states that these services will be provided in a

participating Medicare or Medicaid facility that offers a

home-like atmosphere and ensures that patient areas are

designed to preserve the dignity, comfort and privacy of

patients.


inpatient care is dictated by a patient’s medical need and

that if possible, symptoms are addressed in the patient’s

home environment. Admission to a HMC general inpatient

bed is based on one or more of the following acute care

admission criteria:

Pain control

Symptom control

Imminent death with symptoms necessitating frequent

physician and nursing intervention

Medical-surgical procedures or therapies aimed at

palliation of symptoms

Family education needs necessary in order to follow the

established plan of care at home


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Provision of a safe and supportive environment to the

terminally ill individual during periods of acute

psychosocial and/or spiritual breakdown of the primary

caregivers

Primary caregiver incapable of continuing daily care in

the home setting


states that circumstances under which a patient will be

admitted to an inpatient bed depend upon the patient’s

physical condition and the home care situation. The

applicant maintains that it has the ability to deliver

continuous care services at home to its patients, enabling

the ability to avoid admission to inpatient units.

VHCF has written guidelines defining patient and facility

eligibility for facility-based care. Any facility with which

VHCF contracts for hospice care must meet appropriate

licensing, regulatory and certification requirements.

Facilities must have an environment that ensures the

comfort and safety of each patient, accommodates

personalized patient-directed treatment and promotes family

involvement in care giving.

(j) Provisions for serving persons without primary

caregivers at home.


(CON #10140) maintains that it is committed to serving all

patients including those who do not have primary caregivers

at home as evidenced by its history of serving these patient

populations in its existing markets.

In the case that a patient is not able to care for him/herself

and has no caregiver support group, Compassionate Care

may recommend placement in an assisted living facility or

nursing home in which it will be able to provide residential

care. Compassionate Care social workers will assist patients

without financial resources to obtain residential care in a

hospice unit within an assisted living facility or nursing

home, as determined by their medical condition. The

applicant proposes to establish relationships with area

nursing homes and assisted living facilities as the need

arises.


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The applicant asserts that it is intimately familiar with

appropriate methods and techniques for provision of care to

special needs populations including those without

caregivers. Compassionate Care states that it will be able

and willing to meet similar needs in Hospice Service Area 3E. Harbor Light Hospice of Florida, Inc. (CON #10141)

indicates that if a patient does not have a caregiver, a social

worker will immediately develop a plan of care to provide for

care and present options to the patient, including providing

assistance in securing a bed in an appropriate facility. The

applicant states that upon assessment, the social worker will

assist family in accessing appropriate community resources.


it serves patients without caregivers by working to develop a

plan to them the care they need when they can no longer

care for themselves. The applicant states that in such cases,

it would be able to provide residential care services as

routine as home care to any hospice patient in a nursing

home or assisted living setting. HMC maintains that its

Tuscany House may serve as an alternative for persons

without primary caregivers at home.


maintains that terminally ill patients with no at home

support will receive increased attention from the hospice

staff. The applicant states that every effort will be made to

develop a caregiver network from among neighbors, nearby

relatives and friends, church members and hospice

volunteers who will be capable of providing the necessary

amount of supervision, assistance and companionship

within the patient’s or caregiver’s home.

Patients living alone with the ability to care for him or herself

for the most part, will be assisted by the applicant in

developing a network of caregivers to assist the patient or

recommend that qualified adult sitter services be obtained

should that not pose a financial hardship. VHCF may

provide patients or family members with cell phones for 24-

access and communication to those who may have none

available. Where appropriate, the applicant will provide

continuous care to allow the patient to remain at home.


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(k) Arrangements for the provision of bereavement services.


(CON #10140) states that its policy is to provide appropriate

and coordinated bereavement services/counseling to families

and caregivers as well as residents/staff of skilled nursing

facilities, assisted living and other medical facilities for at

least 13 months following the death of the patient.

Bereavement services will begin with an initial bereavement

risk assessment to be completed by the social worker,

bereavement coordinator or designee within five days of

admission. Compassionate Care states that the bereavement

coordinator may also provide supportive counseling prior to

the death of the patient. Within three to five weeks after the

patient’s death, the bereavement follow up assessment is

completed by the bereavement counselor following the

patient’s family/caregiver. The applicant maintains that

persons deemed to be experiencing moderate or severe grief

will receive increased services.

The applicant states it also provides bereavement support for

children, called Compassionate Courage. The children

participate in art, reading, poetry, writing exercises, group

discussions, drawings, memory collages, a “feeling toss”

game and books.


that while patients are receiving hospice services, a

bereavement plan of care is developed to recognize

anticipatory grief and identify any additional bereavement

support that families may require for a minimum of 13

months following the death of a loved one. Bereavement

support can take a variety of forms including: telephone

calls, visits, written materials about grieving and support

groups.

The applicant will provide support groups for bereaved

families who have experienced the death of a loved one. This

service will be offered to any member of the community who

has experienced the death of a loved one. Bereavement

services to be provided include:


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Contacts from the interdisciplinary team

Grief support programs for families by social workers and

spiritual care

Memorial services

Individual grief support

Educational programs on grief and bereavement to the

community

Holiday grief programs

Resource information on grief


that it has extensive policies and procedures in place for the

provision of bereavement services. The applicant states that

the patient, caregiver(s) and family are assessed for coping

skills and bereavement risk factors periodically. Interested

families are referred to the bereavement department while

high-risk referrals are called into the bereavement

department immediately. Community patients may be self-

referred or referred by appropriate individuals/professionals.

The applicant states that services provided through the

bereavement center include:

Individual and family grief support

Grief support for children

Grief support groups

Camp Mariposa

School support groups

Memorial services

Community outreach

Resource materials

Referrals


states that staff and volunteers will provide bereavement

services. The applicant states that bereavement services are

appropriate from the time of the nursing assessment until

the primary tasks of mourning are accomplished and the

survivor can emotionally reinvest into life and other

relationships.


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VHCF indicates that bereavement support will be available

24 hours a day, seven days a week. A psychosocial staff

person who has been trained in providing bereavement

support will be listed on the on-call schedule and be

accessible through a toll-free number. Core grief services to

be offered to families include:

Grief supportive counseling

Home visits

Bereavement group activities

Volunteer support

Patient/family grief education materials

Quarterly follow-up/correspondence

Memorial gatherings

Resources and referrals

Staff bereavement support

Community grief education and events

The applicant states that the bereavement program will be

under the direction of the volunteer/bereavement manager

who will be responsible for establishing bereavement services

and running the day-to-day bereavement program. The

goals and objectives of the bereavement team at the of a

patient’s death are as follows:

Facilitating the experience of sadness, loss and grief

following the death of a loved one.

Validating the many experiences that are felt by those

who grieve.

Offering support and guidance to family members and

friends who have experienced a loss.

Identifying complicated/abnormal mourning and initiate

resources to assist the family.

VHCF cites that it institutes staff bereavement support as

well. The general manager is responsible for assuring that

grief support is provided to staff and volunteers through

private consultation and regularly scheduled meetings. In

addition, direct patient care staff are given the opportunity

for closure with the family by making a closure visit or phone

call after the death of the patient.


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(l) Proposed community education activities concerning

hospice programs.


(CON #10140) indicates that it will provide extensive

community education activities surrounding the benefits of

hospice to increase hospice awareness and utilization. The

applicant states that it has forecasted one FTE for a

professional relations coordinator in year one and year two of

operation as well as 0.5 FTE in year one and 1.0 FTE in year

two for a clinical liaison.24 These individuals will be

responsible for leading the outreach for specific disease

focused programming, veterans outreach, further developing

relationships through the community, coordinating

educational sessions, presentations and other outreach

activities.

The applicant indicates that it will host hospice educational

events at senior organizations, religious affiliated groups,

veterans’ organizations, health fairs, skilled nursing homes

and assisted living facilities to educate the residents of Lake

and Sumter Counties on the benefits of holistic end-of-life

care through hospice.


that it has a strong history of offering educational

opportunities to the communities that it serves. The

applicant indicates that the educational opportunities focus

on hospice and the issues surrounding hospice care and will

be offered to the general public in community centers,

Alzheimer Association meetings, health fairs, churches,

senior organizations and other local groups. Harbor Light

offers educational programs in skilled nursing facilities,

retirement communities, assisted living facilities and other

health care facilities/organizations. The applicant provided

a list of sample topics for these educational programs on

page 73 of CON application #10141.

24 Compassionate Care does not have a clinical liaison listed on Schedule 6 (staffing) but does have a community liaison listed for 0.5 FTE (year one) and 1.0 FTE (year two).


88

The applicant indicates that it offers educational programs

specifically to meet the needs of clinicians in the community.

Harbor Light provides a list of social work board approved

programs on page 73 of CON application #10141.

Harbor Light commits to sponsoring four education seminars

per year for physicians, long-term care facilities and assisted

living facilities. The applicant commits to at least 0.5 FTE of

staff manpower for community education specialist,

expanding community awareness of hospice services.


that it currently has an active and effective community

outreach and education program in Marion County, adjacent

to Hospice Service Area 3E. The applicant maintains that it

is adept at operating this program, hosting and sponsoring

numerous community events. Staff members have

performed outreach to the following types of

groups/organizations:

Senior centers

Businesses

Health fairs

Churches/synagogues

Schools

Chamber of Commerce

Community centers

Libraries

Hospitals

Town halls

Neighborhood groups

Skilled nursing facilities and assisted living facilities

Non-profit organizations

The applicant states that special community education

efforts, clinical care protocols and bereavement services will

be implemented to increase participation in hospice for

groups traditionally underrepresented in the service area,

especially those of Hispanic heritage. HMC asserts that it

will employ bilingual, Spanish-speaking staff to assist in

these efforts.


89

HMC plans a considerable marketing campaign to launch

the proposed program into the services area and foster

community support through regular and frequent

educational seminars. The applicant contends that by

educating the public about the benefits of hospice care,

utilization is expected to increase for all hospice providers in

the area.


proposes to educate the Subdistrict 3E community through

public forums such as seminars and community education

at churches, schools and other social organizations. The

applicant states that it will offer in-house training to keep

subdistrict health care facilities informed of hospice issues.

VHCF identified numerous groups to which it will provide

education, attend meetings and develop protocols, including:

Florida Health Care Association

Florida Assisted Living Association

Florida Association Directors of Nursing Administration

American Legion

Veterans of Foreign Wars Chapter

Local nursing homes

Local assisted living facilities

United Way

The applicant indicates that it offers many area schools

internship positions and educational opportunities for their

students as a community service. Student LPNs and RNs

participate by doing rotation with the VITAS Hospice

program. In addition, VHCF has condition approval of this

application upon a charitable contribution to United Way of

Lake and Sumter in the amount of up to $225,000 during

the first two years of licensure.

VHCF states that education activities that will be implement

in Subdistrict 3E, upon approval, will include:

Hospice overview

Coping with loss

Pain management

Advance directives


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Children and death

Psychological reaction to terminal illness

Psychological reaction to death

Stress management

Coping with sorrow

Care techniques

The applicant provided a list of projects within communities

where it has chosen to participate both financially and

through employee volunteerism within the following areas of

interest: education, health, civic and culture/arts. VITAS

states that it has made a real commitment to the

communities it serves and provides some benefits it has

supplied. The applicant asserts that it will encourage

involvement in community activities and provide financial

contributions as it can.

(m) Fundraising activities. Compassionate Care Hospice of Lake and Sumter, Inc.

(CON #10140) indicates that it has a relationship with

Compassionate Care Hospice Foundation, an unrelated not-

for-profit 501(c)3 organization. The foundation’s mission is

to provide the resources necessary to support the

extraordinary needs of hospice patients and their families.

The applicant states that it will not actively raise funds from

the community but if an individual wants to make a

charitable donation, they will be directed to Compassionate

Care Hospice Foundation’s website. Compassionate Care

conditioned approval of CON #10140 on the provision it will

not participate in fundraising activities in Subdistrict 3E. Harbor Light Hospice of Florida, Inc. (CON #10141)

asserts that it will not perform any local fundraising

activities in direct support of its operations. All program

services and activities will be funded by the hospice’s

operations. The applicant indicates that any unsolicited

donations received will be dedicated directly to the

enhancement of its programs in Lake and Sumter Counties.

Harbor Light maintains that the proposed program will have

no impact on the fundraising activities of the existing local

provider.


91


that it regularly receives reimbursement from third-party

payers—increasingly relying on donations to more fully carry

out its mission and vision. The applicant contends that

several factors contribute to this increasing reliance:

The current economic downturn has created increasing

unemployment and less cash for personal spending on

self-pay and for donations.

The amount of charity care provided in 2011 was

$924,279 and through March 2012, it was $161,223.

Hospice reimbursement increases do not meet increasing

inflation of operating expenses, and it is anticipated that

reimbursement will be cut in upcoming years.

Length of stays are very short with 36 percent of patient

on service for 0-7 days.

The organization’s hospice houses are of an age that

requires increased maintenance.

Direct competition has created a need to spend more

dollars in non-patient care expense.

Technology costs will likely increase over the next several

months.

The applicant states that like most hospice programs, it will

rely upon alternative sources of funds to help subsidize its

operations. HMC commits to use the profits of the Thrift

Store, located in The Villages, to provide support for non-

reimbursed programs and charity care for Subdistrict 3E

residents.

HMC indicates that it undertakes a wide variety of

fundraising activities as well as various levels of memorials

and named gifts. Families, friends and other who have been

positively impacted by the applicant’s services can also give:

Lead trusts

Stocks, bonds, annuities

Real estate

Charitable remainder trusts

Bequests and wills

Life insurance gifts


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The applicant notes that it sponsors, participates in or

otherwise supports a wide array of community benefit events

such as horse events, golf tournaments galas, etc. HMC

states that it has four thrift stores as well; the items are

donated by supporters and are sold with proceeds going

directly to patient care.


agrees that it will not engage in any fundraising events or

campaigns to obtain charitable contributions from residents

of the subdistrict. VHCF will respond to inquiries from

persons seeking to make charitable contributions for hospice

services with information on relevant 501(c)(3) organizations

that benefit Florida residents. Therefore, the applicant

contends, it will not dilute the potential contributions

available in the community or adversely impact existing

hospice programs and their fundraising efforts.

3. Statutory Review Criteria

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

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

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 3E.

The following chart illustrates hospice admissions for the past five years.

As shown below, admissions increased from 2,673 in CY 2007 to 2,817

in 2011. However, the CY 2011 total was greater than only CY 2007’s

during the five years.

Hospice Admissions for Service Area 3E

Calendar Years 2007-2011 Calendar Year Admissions

2011

2010

2009

2008

2007

2,817

2,958

2,979

2,875

2,673 Source: Agency for Health Care Administration Florida Need Projections for

Hospice Programs, 2008-2012.


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states that the Hospice Service Area 3E provider has demonstrated an

increasing failure at serving the market, particularly non-cancer patients

age 65+, resulting in the published need for one additional hospice

provider.

The applicant determined that those diagnosed with end-stage

cardiovascular disease are the leading cause for the gap in those

underserved by hospice. There was a 48 point disparity between non-

cardiac penetration (65.5) and cardiac penetration rates in Hospice

Service Area 3E in calendar year 2010. Compassionate Care contends

that had resident 65+ who died from cardiac disease accessed hospice at

the non-cardiac rate there would have been 584 additional cardiac

admissions to Cornerstone Hospice in calendar year 2010.

In addition to the terminally-ill end stage cardiovascular disease

residents, Compassionate Care asserts it will be a general hospice in

order to meet the needs of all other terminally diagnosed patients,

including cancer patients, in Hospice Service Area 3E.

The applicant indicates that its parent company is in compliance with

the conditions of participation for hospice providers of services under the

Health Insurance for the Aged and Disabled Program as well as the

Medicaid Program. Compassionate Care notes that it has never had

Medicare cap issues, other investigations or focused reviews unlike the

competing applicants in the current batching cycle.

Compassionate Care maintains that it is willing to accept any conditions

on its certificate of need based on any representations made in CON

application #10140. The applicant states that it will provide all required

core components of hospice care set forth by Medicare conditions of

participation as well as Florida hospice licensure requirements.

Compassionate Care asserts that it is a quality focused provider which

invests in the successful training, education, treatment and resources for

staff, physicians, patients and families.

The applicant states that it is a subsidiary of a much larger organization

that has 19 years of experience and has developed several quality

hospice programs throughout the nation. The parent company has a

comprehensive policies and procedure manual that covers a myriad of

topics. Compassionate Care indicates the familiarity with hospice and

the advantage of having the tried and true policies of its parent company

will enable it to provide care in Hospice Service Area 3E in the most

efficient manner.


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Compassionate Care indicates that it will contract for certain services

through the most appropriate and efficient contracts—whether that be

through existing national contracts, extending contracts it has in other

Florida markets or through local contracts. The applicant states it will

ensure staff is educated in the provision of appropriate, high quality

effective and efficient services enabling patients to receive the most

appropriate pain and symptom management to meet the needs.

The applicant contends that hospice services in Lake and Sumter

Counties are currently inaccessible to many qualified patients/families

as evidenced by decreasing penetration rates and the resulting gap in

hospice admissions. Compassionate Care maintains that by approving a

different type of provider, a medium-sized for-profit provider, the Agency

can be assured that access will be enhanced.

The applicant asserts that there is an overwhelming need for end-stage

heart disease patients in Hospice Service Area 3E to have enhanced

access to hospice. Compassionate Care notes that eight cardiologists

offered support for CON application #10140, with three of these

cardiologists quantifying the number of hospice eligible cardiac patients

they currently treat—between 60 and 90. The applicant states that this

supports the need for its Cardiac Connections Program and its forecasted

cardiac volume of 55 in year one and 165 in year two.

Compassionate Care will also provide Veterans programming, specialized

bereavement groups and other disease specific programming such as the

Promise Program for renal disease. In conclusion, the applicant asserts

that it will provide programmatic (clinical) access to appropriate care,

educate the constituent population and provide the highest quality of

patient care possible. Compassionate Care states that its parent

company has history of serving Medicaid recipients and the medically

indigent.

Harbor Light Hospice of Florida, Inc. (CON #10141) states that in

addition to the identified need for one additional hospice program, the

proposed program will expand availability of hospice care throughout the

Lake and Sumter communities as well as enhance access to care for all

components of the local communities.

The applicant indicates that the area is currently served by a single

hospice provider and approval of the proposed program will provide the

incentive for the existing hospice provider to improve and expand the

level of service provided to the residents of Lake and Sumter Counties.


95

Harbor Light maintains that the development of the proposed program

will introduce direct competition, resulting in the residents of Lake and

Sumter Counties receiving more and better hospice services.

Harbor Light Hospice of Florida, Inc. is a newly formed corporation part

of a larger organization with a strong reputation for providing quality

hospice for 18 years. The parent company’s on-going commitment to

providing quality hospice services is further demonstrated by its

commitment to seeking accreditation status from The Joint Commission.

Harbor Light indicates that The Joint Commission accredited policies

and procedures in place at Harbor Light’s Nebraska location will be the

basis for the policies and procedures to be reviewed and/or developed for

the proposed program in Hospice Service Area 3E.

The applicant states that it has developed or is in the process of

developing or formalizing existing services into specialty programs to

meet the needs of patients, including: palliative care, Hispanic/Latino

services, wound care, dementia/Alzheimer’s, deaf/hearing impaired,

veteran’s and cardiac services.

The parent company to the applicant has a quality assurance/

performance plan in place at every hospice location and provides an

organization wide “Clinical Practice Council.” The mission of this council

is to ensure quality service delivery and sound performance based on

best clinical practices. The goals of the council include:

Providing quality assurance and safety review

Ensuring compliance with regulatory requirements

Standardizing education and resources for clinical staff and clinical

managers

Reviewing or current clinical policies

Developing new clinical policies and procedures

Implementing of new clinical procedures

Harbor Light states that it has developed a detailed start-up checklist to

utilize for a new business/office development with three major phases:

preparation phase, implementation phase and monitoring phase. The

applicant states that this plan gives it the ability to hire excellent staff

and involve dedicated volunteers, resulting in the provision of excellent

patient care and the development of strong relationships with referral

sources.


96

The applicant contends that there is significant hospice market

expansion potential in Hospice Service Area 3E, with a large number of

local residents currently un-served by needed hospice services. Harbor

Light notes that Subdistrict 3E fell just below the Florida average (65.83

percent) with 65.24 percent of all deaths served by hospice, but far below

Hospice Service Area 3C, with the highest hospice utilization rate

observed in State: 89.14 percent. The applicant indicates that an

improvement in hospice utilization for non-cancer patients under age 65

and 65+ is needed and achievable.

Hospice of Marion County, Inc. (CON #10142) asserts that availability,

accessibility, quality of care and extent of utilization in Hospice Service

Area 3E will be improved with the proposed program, primarily as the

result of HMC’s experience, capability and its existing relationships in

the market.

The applicant notes that Hospice Service Area 3E’s penetration rate has

decreased between 2009 and 2011 and states that it is confident that the

extent of utilization of hospice services has substantial room for growth

in Lake and Sumter Counties. HMC states it is well-positioned to

recognize, define and develop strategies to overcome the remaining

barriers and obstacles of access and availability in Hospice Service Area

3E.

HMC indicates that the most significant barrier in the access and

availability of hospice services in the future include:

The continuing ignorance of hospice care among potential consumers

and beneficiaries

Learning of hospice benefits too late to take full advantage of services

Attitudes among potential patients and health care professionals that

resist acknowledgement of death as the likely outcome of a particular

disease process until that process nears its end

The applicant cites its history of strong growth in admissions and the

penetration rate in its adjacent, existing services area as powerful

evidence of its level of understanding the barriers to hospice services that

continue to exist. HMC contends that its staffing plan for Hospice

Service Area 3E, at least 20 FTE positions from the initiation of services,

will be directly involved on a daily basis in communicating with,

educating, and informing the general public and the health care

community.25

25 The reviewer notes that the applicant has a total of 13.70 FTEs of staff added by the proposed project for year one in Schedule 6A.


97

HMC asserts that it has created outreach and patient care programs to

address the needs of the Hispanic and veteran communities as utilization

of hospice services varies among different ethnic/racial and population

groups. The applicant contends that when all persons can benefit from

receipt of hospice services at the most effective time in the dying process,

it clearly has a strong and advantageous impact upon quality of care.

The applicant indicates that it currently serves patients in adjacent

Marion County and therefore will be able to initiate high level services

quickly and efficiently upon approval. HMC states that it is prepared to

implement services in Hospice Service Area 3E by January 2013, upon

approval and lack of challenge on the decision. The applicant will

establish a care team office near northern Sumter County is its existing

inpatient hospice facility to implement services and a second care team

office in Leesburg upon initiation of operations.26 HMC asserts that it

will use its vast resources and ability as a regional provider to meet the

growing needs of the district.

HMC expects that its efforts will result in an increase in the current

penetration rate in Hospice Service Area 3E, from the estimated 58.3

percent for 2011 to an anticipated 65.1 percent by calendar year 2015.

The applicant contends that this is consistent with its recent history in

Marion County. HMC asserts that such an increase in the projected level

of hospice care will be a clear enhancement in the existing availability,

accessibility and extent of utilization in Hospice Service Area 3E.

VITAS Healthcare Corporation of Florida (CON #10144) indicates that

it will provide a choice of hospices to residents of Hospice Service Area

3E and increase outreach to underserved population groups as well as

the population as a whole to increase admission rates. The applicant

indicates that state policy dictates the need for the proposed program as

shown by the extent of utilization by the existing hospice service.

VHCF is projecting year one admissions of 214 patients and year two

admissions of 423 patients. The applicant maintains that this is a

reasonable projection based on its recent Florida experience. VHCF

notes that Cornerstone had a total of 4,251 admissions statewide and

2,817 admissions in Hospice Service Area 3E in calendar year 2011.

26 Hospice of Marion County’s existing Tuscany House is located at 17395 SE 109th Terrace Road, Summerfield, Florida—an unincorporated community in Marion County.


98

The applicant states that it is compliance with the conditions of

participation for hospice providers of services under the Health

Insurance for the Aged and Disabled Program as well as the Medicaid

program. VHCF maintains that it has many unique features that

enhance quality of care, including:

Providing continuous care to keep patients comfortably at home

which is the most desired location for terminal patients. By year two

VHCF will provide at least five percent of total patient days in

continuous care.

Implementation of procedures to produce a 70 percent reduction in

pain score within 48 hours (a much higher standard than the 50

percent in 96 hours as identified in Florida Statutes).

Culturally sensitive programs developed in conjunction with leading

national agencies to address African-American, Hispanic/Latino and

other cultural and religious ethics, practices and beliefs.

Providing telecommunication resources for patients to maintain

contact with caregivers.

Significant technological investment to enhance patient care.

Twenty-four hour staff availability with patient records at their

fingertips to immediately respond to patient and family inquiries.

Extensive commitment to training programs (WINKS, THINKS, INET

and others).

Having every patient assessed by a physician within 24 hours of

admission to the hospice. Medical directors visit patients in their

residence.

Medical directors must be board-certified in hospice or palliative care

medicine, or apply for board certification within five years of

employment.

RNs are encouraged to become certified in hospice and palliative care

nursing. By the second year of operation, 50 percent of all

supervisory nurses will attain such certification.

Masters of Divinity or equivalent graduate degree from an accredited

seminary or theological school required for chaplains.

Social workers have a Master’s degree or are licensed clinical social

workers.

VHCF maintains that hospice offices increase the visibility of a hospice in

the community. The applicant states that it has conditioned approval of

CON #10144 upon the provision that it will open offices in both counties

during the first year of operation. The initial office will be located in the

Leesburg area. VHCF will rely on conversations with health care

providers, public officials and community leaders in Sumter County as

well as its early operations experience to determine where to locate the

office in Sumter County.


99

The applicant asserts that it is well known throughout the communities

where it provides services and welcomes charity care patients. The

applicant indicates that VITAS provides in excess of one percent of

revenues in charity care—amounting to approximately $9.9 million in

2011, and VHCF provided $4.5 million in charity care.

VHCF indicates that it, and its parent, have the scale and experience to

establish and operate extremely efficient hospice programs. The

applicant provides some factors that contribute to this efficiency:

VITAS has successfully started four hospices nationwide since 2010,

including a hospice in Florida. Since 2001, it has had 26 successful

hospice startups. VITAS has the experience and resources to start a

hospice in Subdistrict 3E quickly and inexpensively. The last two new

hospices in Florida granted to VITAS were licensed in an average of 34

days after final CON approval.

VHCF is the highest volume hospice in Florida, licensed to served 16

counties, where over half of Florida’s population resides. Establishing

a hospice in Subdistrict 3E will be an extension of existing services.

All VHCF operations are under a single Medicare provider number

and VHCF services in Subdistrict 3E will not require separate

Medicare certification.

VHCF operations in Subdistrict 3E will not require a separate state

license.

VHCF already has in place the information technology, human

resources, training and managed care contracts needed to support

services in Subdistrict 3E.

For vendors who provide goods and services statewide, VHCF already

has supply contracts in place and will not need to negotiate new

contracts before commencing services in Subdistrict 3E.

The applicant states that VITAS, recognizes it responsibility to admit only

appropriate patients and has taken several important steps in this

regard, including:

VITAS performs patient eligibility review at local and corporate levels

VITAS’ admissions criteria is used to ensure that only individuals

whose condition is appropriate for hospice care are admitted

VITAS created the VITAS Hospice Eligibility Reference Guide App


100

VHCF indicates that VITAS’ experience with patients who remain in

hospice over six months is nearly identical to the national average. The

applicant notes that during 2011, less than 11.9 percent of all of VITAS’

admissions had a length of stay longer than six months. Data published

by the NHPCO reported that 11.8 percent of all patients in 2009 and

2010 stayed in hospice care for longer than 180 days nationwide.

The applicant will place a priority of the following components:

Managing customer expectations

Training and expert staff

Making each customer encounter successful

Proactive quality monitoring

Applying research experience to improve patient care

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

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


states that it is a shell entity and therefore has no operational history.

However, its parent company has been providing quality hospice care for

19 years and it recently successfully initiated hospice service in Hospice

Service Area 6B (Polk, Highlands and Hardee Counties). The applicant

indicates that it will rely upon the parent’s wealth of knowledge,

expertise, experience and skills in developing and operating within

Hospice Service Area 3E.

The applicant notes that its parent company has 32 hospice programs in

approximately 56 office locations operating in 21 states. In addition to

initiating services in Hospice Service Area 6B, the parent company has a

pending certificate of need application to serve Miami-Dade and Monroe

Counties awaiting a final decision from Florida’s Division of

Administrative Hearings.

Compassionate Care states that the parent’s operations have had no

licensure violations and no Medicare cap issues. All programs are either

already enrolled in both Medicare and Medicaid programs or are actively

awaiting certification. The parent is a member of the National Hospice

and Palliative Care Organization and ascribes to its policies and

procedures.


101

The applicant maintains that its parent commitment to quality care

manifest in a variety of ways including:

High levels of planned employee staffing standards that surpass

NHPCO recommended guidelines in positions such as a 1:3 aide to

patient ratio in home health aides

Uniquely tailored programs that go beyond core hospice services

Commitment to provide all four levels of care (routine, inpatient,

respite and continuous care) as needed

Expertise in start-up operations throughout the county, with a focus

on catering to the needs of every local market

Compassionate Care states that the parent has provided the utmost in

quality care to its patients and their families. The applicant provided a

list of activities the parent currently participates in to achieve this

quality, including:

CHAP Accreditation

Surpassing NHPCO staffing standards as well as national

benchmarks

A Quality Assessment and Performance Improvement Plan

Benchmarking

Patient/family satisfaction surveys

Continuing education, in-service training and memberships in quality

associations

Agency records indicate that Compassionate Care had one substantiated

complaint for the period since it initiated service in Hospice Service Area

6B on February 22, 2011. The substantiated complaint was related to

resident/patient/client rights. It is noted that the applicant did not

participate in voluntary reporting between October 2011 and December

2011, on the Florida Health Finder, Hospice Provider Family Satisfaction

Survey.

Harbor Light Hospice of Florida, Inc. (CON #10141) indicates that it is

a newly formed Florida organization with a parent company that has five

separate entities providing hospice services in 19 locations in eight

states. All of the parent company’s hospice locations are licensed by the

states in which they operate and are Medicare and Medicaid certified.

The applicant states it has conditioned the approval of CON application

#10141 that the proposed program will receive Joint Commission

accreditation by the end of the first year of operation.


102

Hospice of Marion County, Inc. (CON #10142) states that it has a long

and distinguished history of providing quality of care to its patients. The

applicant notes that it is accredited by the Joint Commission and is

licensed by the Agency for Health Care Administration. HMC is a

provider of Medicare/Medicaid benefits, a member of the National

Hospice and Palliative Care Organization, a member Florida Hospices

and Palliative Care, Inc. and was recently selected as one of nine

hospices in the nation to participate in the Center for Medicare and

Medicaid Services quality reporting initiative.

The applicant provides pertinent dates in the development of its existing

program on page 149 as well as a list of awards it has received in recent

years on page 150 of CON application #10142. HMC states that it

operates in compliance with all federal, state and local statutes,

regulations and ordinances. The applicant indicates that operating

policies, procedures, practices and protocols are in place as well as the

QAPI Plan which will be utilized to initiate services in the proposed

program. HMC asserts that it is fully confident in its ability to extend its

existing high quality hospice care program throughout neighboring

Hospice Service Area 3E.

Agency records indicate that HMC had no substantiated complaints for

the three-year period ending June 26, 2012 in hospice service area 3B.

It is noted that the applicant did participate in voluntary reporting

between October 2011 and December 2011, on the Florida Health

Finder, Hospice Provider Family Satisfaction Survey. HMC had between

68 and 79 survey respondents receiving five star ratings (90 to 100

percent satisfaction) in all categories.

VITAS Healthcare Corporation of Florida (CON #10144) states that it

is an existing licensed hospice and has been in operation for more than

30 years, setting the standard for other hospices as well as extensive

experience in the operation of hospices throughout Florida. VHCF

programs have earned hospice accreditation from the National Institute

for Jewish Hospice as well as The Joint Commission and CHAP. In

addition, the corporate body of VITAS maintains current accreditation by

The Joint Commission and CHAP.

The applicant notes that the proposed program will operate under an

existing Medicare provider number and may not justify the delay and

expense of an external accreditation process. VHCF asserts that

regardless of external accreditation, the proposed program in 3E will

adhere to the same policies, procedures and standards for the VITAS

programs that are externally accredited.


103

VHCF provides a timeline of its history and quality of care on pages 98-

99 of CON application #10144—including that it has provided hospice

services since 1978, has an average daily census of over 5,000 patients

and serves more than 24,400 patients annually.

The applicant indicates that it will implement a quality assurance

program consistent with its existing programs in Florida. The objectives

of VHCF’s Quality Improvement Program are as follows:

To identify patient care quality areas for improvement

To ensure the care provided is appropriate to patient needs

To revise procedures as necessary

To attain these objectives, VHCF will establish and implement a system

to:

Continually assess and improve the care and services provided to

patients and their families

Routinely collect and report data on the quality of care

Annually conduct an overall review of the program and all services

provided

Annually complete studies of symptom management, stress,

continuity of care and inpatient care

The applicant states that the information obtained via the quality of

services and quality of outcomes monitoring is reviewed by the joint

practice/utilization review committee. The committee meets at least

quarterly to review audit results, infection and incident tracking,

complaint patterns and resolution, outcomes management reports and

performance improvement activities.

VHCF employs a satisfaction survey to determine how well it is meeting

the needs of patients, families, referral sources and attending physicians.

VITAS will provide access to both the surveys and to software for

analyzing survey results by computer.

Agency records indicate that VHCF has four substantiated complaints for

the three-year period ending June 26, 2012 in hospice Service Areas 4A,

4B, 7A, 7B, 7C, 8B, 9C, 10 and 11. A single complaint can encompass

multiple complaint categories.


104

VHCF Substantiated Complaint Categories in the Past 36 Months

Complaint Category Number Substantiated

Administration/Personnel 2

Quality of Care/Treatment 2

Nursing Services 2

Plan of Care 1

Resident/Patient/Client Assessment 1 Source: Agency for Health Care Administration complaint records.

It is noted that the applicant did participate in voluntary reporting

between October 2011 and December 2011, on the Florida Health

Finder, Hospice Provider Family Satisfaction Survey and was listed under

three different headers. VITAS Healthcare Corporation of Florida

22910014, North Miami Beach had between 214 and 275 survey

respondents. VITAS Healthcare Corporation of Florida, 22960083,

Boynton Beach had between 281 and 383 survey respondents. VITAS

Healthcare Corporation of Florida 22960086, Melbourne had between

168 and 201 survey respondents. All three received five-star ratings (90

to 100 percent satisfaction) in all categories.

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.


(CON #10140): The audited financial statements of the applicant were

reviewed to assess the financial position as of the balance sheet date and

the financial strength of its operations for the period presented.

The applicant is a Florida for-profit corporation and a development stage

company that was formed on April 6, 2012, for the purpose of operating

a hospice in Florida, with net assets of $150,000 and no liabilities for the

period ended June 5, 2012. As of 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 $152,965 which is the CON

subject to this review and capital expenditures. In addition, the

applicant will have to fund the projected year one operating loss of

$292,402.


105

Available Capital:

The applicant provided a letter from Compassionate Care Group, Ltd

(Parent) which states the parent will provide funding for the project. The

applicant states that the parent’s December 31, 2011 financial

statements show $3.5 million available for taxes and investments.

However, no audited financial statements of the parent were provided,

only an unaudited profit and loss statement. The parent provided a

letter, dated June 27, 2011, from TD Bank indicating the parent has a

$2,000,000 revolving line of credit. The parent did not provide a

statement from the bank indicating the current available balance in the

revolving line of credit. Without a current available balance for the line

of credit and/or current audited financial statements, we cannot rely on

the information presented in the application that would support the

parent’s ability to fund the project. Therefore, funding for this project is

in question. Staffing:

Compassionate Care Proposed Staffing for Subdistrict 3E

April 2013-March 2015 First Two Years of Operation

Position



Administrator 1.0 1.0

Professional Relations Coordinator 1.0 1.0

Secretary 1.0 2.0

Community Liaison 0.5 1.0



Registered Nurses 2.0 4.5

Per Diem Registered Nurses 0.3 1.0

LPN 0.0 1.0

Per Diem LPN 0.0 0.5

Nurses’ Aides 6.0 14.0

Nurse Practitioner 1.0 1.0

Per Diem Nurses’ Aides 0.4 1.6

Continuous Care Per Diem LPN 0.6 1.81

Continuous Care Per Diem Aide 0.6 1.81

Life Enhancement Specialist 0.2 1.0

Music Therapist 0.2 0.5

Massage Therapist 0.2 0.5

Dietary Services 0.2 0.5


Volunteer Coordinator 0.5 1.0

Chaplain 0.5 1.0

Total 18.4 40.22 Source: CON application #10140, page 87.

Conclusion:

Funding for this project is in question.


106

Harbor Light Hospice of Florida, Inc. (CON #10141): The audited

financial statements of the applicant were reviewed to assess the

financial position as of the balance sheet date and the financial strength

of its operations for the period presented.

The applicant is a Florida for-profit corporation and a development stage

company that was formed on April 26, 2012 for the purpose of operating

a hospice in Florida, with net assets of negative $297 and $297 in

liabilities for the period ended May 31, 2012. The audit indicates that

the applicant is economically dependent upon the stockholders and an

affiliate to provide working capital. As of 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 $176,460 which is the CON

subject to this review. In addition, the applicant will have to fund the

projected year one operating loss of $254,559.

Available Capital:

The applicant provided a letter from its parent corporation, Hospice of

America, Inc. (parent), which states the parent will provide funding for

the project. It should be noted that the applicant included operating

results of its parent. However, the operating results provided by the

parent are unaudited. An audit report gives an independent opinion on

whether or not the financial statements are presented fairly in all

material respects. Without an audit, we cannot rely on the information

presented in the parent’s financial statements. The applicant did provide

a revolving note, signed on 2/24/12, from The Private Bank indicating

the parent has a $2 million revolving line of credit. However, the line of

credit is not guaranteed and subject to disapproval. Therefore, funding

for this project is in question.


107

Staffing:

Harbor Light Proposed Staffing for Subdistrict 3E Calendar Year 2013 and 2014 First Two Years of Operation

Position



Marketing 1.2 2.0

Executive Director 1.0 1.0

Supervisor 0.3 1.2

Office 0.7 1.0

Patient Care Coordinator 0.7 1.0


R.N.’s 1.1 4.7

L.P.N.’s 0.4 1.7

HHAs 1.1 4.7

Bereavement Coordinator/Chaplain 0.3 1.2

MSW/Volunteer Coordinator 0.6 2.4

Total 7.4* 20.9* *These numbers should be 7.42 and 21, respectively.

Source: CON application #10141, Schedule 6A, page 130.

Conclusion:

Funding for this project is in question.

Hospice of Marion County, Inc. (CON #10142): The applicant, a

Florida not-for-profit corporation, provided audited financial statements

for the periods ending December 31, 2011 and 2010. These statements

were analyzed for the purpose of evaluating the applicant’s ability to

provide the capital and operational funding necessary to implement the

project.

Short-Term Position:

The applicant’s current ratio of 1.9 indicates current assets are greater

than current obligations in the amount $3.6 million, is slightly below

average an adequate position. The ratio of cash flow to current liabilities

of 0.6 is below average and a slightly weak position. Overall, the

applicant has an adequate short-term position. (See Table 1).

Long-Term Position:

The ratio of long-term debt to net assets of 0.6 indicates the applicant

has less equity than long-term debt, a weak position. The ratio of cash

flow to assets of 9.0 percent is slightly below average and an adequate

position. The most recent year had an operating gain of $265,292, which

resulted in a 0.9 percent operating margin. Overall, the applicant has an

adequate long-term position. (See Table 1).


108


Schedule 2 indicates total capital projects of $1.19 million which consist

of the CON subject to this review, routine capital equipment and

maturities of long-term debt. In addition, the applicant will have to fund

the projected year one operating loss of $700,784.

Available Capital:

Funding for this project will be provided by the applicant. Based on our

review, the applicant has available working capital of $3.6 million and

cash flow from operations of $2.5 million. The applicant appears to have

sufficient capital to fund this project and the entire capital budget.

TABLE 1

Hospice of Marion County - CON# 10142

12/31/2011

Current Assets (CA) $7,523,494

Cash and Current Investment $4,655,693

Total Assets (TA) $27,584,782

Current Liabilities (CL) $3,907,470

Total Liabilities (TL) $12,751,049

Net Assets (NA) $14,833,733

Total Revenues (TR) $28,432,889

Interest Expense (IE) $498,449

Operating Income (OI) $265,592

Cash Flow from Operations (CFO) $2,492,924

Working Capital $3,616,024

FINANCIAL RATIOS

12/31/2011

Current Ratio (CA/CL) 1.9

Cash Flow to Current Liabilities (CFO/CL) 0.6

Long-Term Debt to Net Assets (TL-CL/NA) 0.6

Times Interest Earned (OI+IE/IE) 1.5

Net Assets to Total Assets (NA/TA) 53.8%

Operating Margin (OI/TR) 0.9%

Return on Assets (OI/TA) 1.0%

Operating Cash Flow to Assets (CFO/TA) 9.0%


109

Staffing:

Hospice of Marion County Proposed Staffing

Subdistrict 3E Calendar Years 2013 and 2014 First Two Years of Operation

Position



Medical Records Clerk 0.5 1.0

Volunteer Services ---- 0.5

All Other Administration 2.75 3.5

Physicians 0.25 0.35


R.N.’s 4.5 6.0

L.P.N.’s 1.5 1.5

Hospice Aides 1.5 3.0

Pharmacy ---- 0.5

Dietician 0.2 0.2


Chaplain 0.5 1.0

Bereavement Counselors 0.25 0.5

Total 13.7 20.55 Source: CON application #10142, Schedule 6A.

Conclusion:

Funding for this project should be available as needed.

VITAS Healthcare Corporation of Florida (CON #10144): The

applicant, a Florida for-profit corporation, provided audited financial

statements for the periods ending December 31, 2011 and 2010. These

statements were analyzed for the purpose of evaluating the applicant’s

and parent’s ability to provide the capital and operational funding

necessary to implement the project.

Short-Term Position:

The applicant’s current ratio of 1.1 indicates current assets are slightly

greater than current obligations, but is below average and a slightly weak

position. The ratio of cash flow to current liabilities of 3.1 is well above

average and a strong position. Overall, the applicant has an adequate

short-term position. (See Table 1).

Long-Term Position:

The ratio of long-term debt to net assets of 0 indicates the applicant has

no long-term debt, a strong position. The ratio of cash flow to assets of

24.3 percent is above average and a strong position. The most recent

year had an operating income of $66,317,556, which resulted in a 17.4

percent operating margin. Overall, the applicant has a strong long-term

position. (See Table 1).


110


Schedule 2 indicates total capital projects of $6.45 million which consist

of the CON subject to this review, current year capital expenditures for

Florida and non-specified capital expenditures.

Available Capital:

Funding for this project will be provided by the applicant. Based on our

review, the applicant has available working capital of $2,780,607 and

cash flow from operations of $63.5 million. The applicant appears to

have sufficient capital to fund this project and the entire capital budget.

TABLE 1

VITAS Healthcare Corporation of Florida - CON# 10144

12/31/2011

Current Assets (CA) $23,144,885

Cash and Current Investment $0

Total Assets (TA) $260,917,116

Current Liabilities (CL) $20,364,278

Total Liabilities (TL) $20,364,278

Net Assets (NA) $240,552,838

Total Revenues (TR) $382,024,540

Interest Expense (IE) $0

Operating Income (OI) $66,317,556

Cash Flow from Operations (CFO) $63,467,807

Working Capital $2,780,607

FINANCIAL RATIOS

12/31/2011

Current Ratio (CA/CL) 1.1

Cash Flow to Current Liabilities (CFO/CL) 3.1

Long-Term Debt to Net Assets (TL-CL/NA) 0.0

Times Interest Earned (OI+IE/IE) N/A

Net Assets to Total Assets (NA/TA) 92.2%

Operating Margin (OI/TR) 17.4%

Return on Assets (OI/TA) 25.4%

Operating Cash Flow to Assets (CFO/TA) 24.3%


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Staffing:

VHCF Proposed Staffing for Subdistrict 3E

October 2012-September 2014 First Two Years of Operation

Position



General Manager/Administrator 1.00 1.00

Admissions/Hospice

Reps/Community Liaison

3.46

4.50

Bereavement Manager 0.71 1.00

Business Manager 0.83 1.00

PC Secretary 1.00 1.50

Receptionist 0.75 2.00

Medical Director/Physician 0.45 0.93

Team Director (RN) 1.25 2.25

Continuous Care Manager 0.00 0.75

RNs 3.06 6.74

LPN/Aides 7.65 24.15

On-Call Representatives 1.58 2.00


Chaplain 1.00 1.13

Total 23.96* 50.78 *This number should be 23.95.

Source: CON application #10144, Schedule 6A.

Conclusion:

Funding for this project should be available as needed.

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

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

The following applies to all applicants. Schedule 7 of the application

indicates that the services to be provided are routine home care,

continuous home care, inpatient respite, and general inpatient care.

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 Broward County,

Florida wage index for Medicare Hospice payments of 1.0499 and inflated

through the appropriate period for each applicant. The average price

adjustment factor used was 2.9 percent per year based on the new CMS

Market Basket Price Index as published in the 1st Quarter 2010 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 for each applicant below.


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(CON #10140): For year two of operations, the applicant projected the

following percentage of total patient days by group: Medicare at 94.1

percent, Medicaid at 3.0 percent, self-pay/charity at 1.3 percent, and

commercial insurance and other payers at 1.6 percent.

The applicant’s projected gross revenue was 0.8 percent, or $27,362, less

than the calculated gross revenue. Operating profits from this project

are expected to increase from an operating loss of $292,402 for year one

to an operating profit of $287,782 for year two.

The applicant offered several conditions to its proposed hospice program.

None of the conditions appear to have a material financial impact to the

projections. Conclusion:

Assuming the applicant can obtain the necessary financing, this project

appears to be financially feasible.

HOSPICE REVENUE TABLE 1

CON #10140 Compassionate Care Hospice of Lake & Sumter, Inc.

Wage Index for Lake County(0.8705)

Wage Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $103.77 0.8705 $90.33 $47.26 $137.59

Continuous Home Care $605.65 0.8705 $527.22 $275.81 $803.03

Inpatient Respite $84.56 0.8705 $73.61 $71.66 $145.27

General Inpatient $430.04 0.8705 $374.35 $241.80 $616.15

Payment Rate

Inflation Factor Year

Two

Inflation Adjusted Amount

Patient Days Year 2,

December 31 -2014

Calculated Gross

Revenue

Routine Home Care $137.59 1.077 $148.24 20,553 $3,046,752

Continuous Home Care $803.03 1.077 $865.17 314 $271,663

Inpatient Respite $145.27 1.077 $156.51 21 $3,287

General Inpatient $616.15 1.077 $663.83 210 $139,404

Total 21,098 $3,461,105

From Schedule 7 $3,433,743

Difference

-$27,362

Percentage difference -0.80%


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Harbor Light Hospice of Florida, Inc. (CON #10141): For year two of

operations, the applicant projected the following percentage of total

patient days by group: Medicare at 92.0 percent, Medicaid at 4.0 percent,

self-pay/charity at 2.0 percent, and commercial insurance and other

payers at 2.0 percent.

The applicant’s projected gross revenue was 0.57 percent, or $13,807,

less than the calculated gross revenue. Operating profits from this

project are expected to increase from an operating loss of $254,559 for

year one to an operating profit of $240,498 for year two.

The applicant offered several conditions to its proposed hospice program.

None of the conditions appear to have a material financial impact to the

projections.

Conclusion:

Assuming the applicant can obtain the necessary financing, this project

appears to be financially feasible.


CON #10141 Harbor Light Hospice of Florida, Inc.



Adjusted Wage


Payment Rate





Payment Rate


Two



December 31 -2014

Calculated Gross

Revenue





Total 14,298 $2,454,771


Difference

-$13,807

Percentage difference -0.57%


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Hospice of Marion County, Inc. (CON #10142): For year two of

operations, the applicant projected the following percentage of total


self-pay/charity at 1.4 percent, and commercial insurance at 3.0

percent.

Based on our calculation, the applicant’s projected gross revenue was

14.5 percent, or $503,910, more than the calculated gross revenue. The

reason for the overstatement is, most likely, an “Other” source of income

which was not identified in the schedules and is not based on patient

days. In any event, overstating revenue is not a conservative assumption

and is potentially unreasonable.

Operating profits from this project are expected to increase from a loss of

$271,773 for year one to a profit of $234,041 for year two. It should be

noted that the $458,577 “Other” revenue has a significant impact on the

profitability of this project. Without such revenue, the project would be

in a loss position for year two.

Conclusion:

This project appears to be financially feasible dependent on the source of

other operating revenue discussed above.


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CON #10142 Hospice of Marion County



Adjusted Wage


Payment Rate





Payment Rate


Two



December 31 -2014

Calculated Gross

Revenue





Total 15,944 $2,981,504


Difference

$503,910

Percentage difference 14.46%

VITAS Healthcare Corporation of Florida (CON #10144): For year two

of operations, the applicant projected the following percentage of total


self-pay/charity at 1.1 percent, and commercial insurance at 2.0

percent.

Based on our calculation, the applicant’s projected gross revenue was

equal to the calculated gross revenue, a conservative position.

Operating profits from this project are expected to increase from a loss of

$651,375 for year one to a profit of $41,399 for year two.

Conclusion:

This project appears to be financially feasible.


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CON #10144 VITAS Healthcare Corporation of Florida



Adjusted Wage


Payment Rate




Physician Services $0.00 0.8705 $0.00 $0.00 $0.00

Payment Rate


Two



December 31 -2014

Calculated Gross

Revenue


Continuous Home Care $803.03 1.062 $852.76 1,383 $1,179,365


Physician Services $0.00 1.062 $0.00 4,905 $0

Total 25,762 $4,801,135


Difference

$0

Percentage difference 0.00%

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

cost-effectiveness? ss. 408.035(1) (g), Florida Statutes.

The following applies to all applicants. Each co-batched applicant is

offering a new choice of provider in the hospice service area.

This application is for a new hospice program in Hospice Service Area

3E, which currently has one existing hospice program. Therefore, this

project is offering a new choice of provider in the Lake and Sumter

service areas.

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.


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With the large majority of patient care being provided from fixed price

government payer sources, this project is not likely to have any

discernible positive impact on price-based competition to promote cost

effectiveness. 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.


(CON #10140): The applicant is projecting 1.6 percent of its patient

days from managed care/commercial insurance payers with 97.1 percent

of patient days expected to come from fixed price government payer

sources (Medicare and Medicaid), with the remaining 1.3 percent as self-

pay/charity.

Harbor Light Hospice of Florida, Inc. (CON #10141): The applicant is

projecting 2.0 percent of its patient days from managed care/commercial

insurance payers with 96.0 percent of patient days expected to come

from fixed price government payer sources (Medicare and Medicaid), with

the remaining 2.0 percent as self-pay/charity.

Hospice of Marion County, Inc. (CON #10142): The applicant is

projecting 3.0 percent of its patient days from managed care/commercial

insurance payers with 95.6 percent of patient days expected to come

from fixed price government payer sources (Medicare and Medicaid), with

the remaining 1.4 percent as self-pay/charity.


applicant is projecting 2.0 percent of its patient days from managed

care/commercial insurance payers with 96.9 percent of patient days

expected to come from fixed price government payer sources (Medicare

and Medicaid), with the remaining 1.1 percent as self-pay/charity.

Conclusion:

These projects are 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.

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.


(CON #10140) states that its parent has an extensive history of

providing services to Medicaid patient and the medically indigent. In

addition, the applicant notes that its Cardiac Connection Program saves

Medicare an average of $22,000 for each person enrolled.

Compassionate Care asserts that it will admit patients to the program,

regardless of their ability to pay. The applicant projects three percent of

total patient days in both years one and two of the proposed program will

be Medicaid payers and 1.3 percent in both years will be provided to

charity care patients.

Harbor Light Hospice of Florida, Inc. (CON #10141) states that its

parent organization’s hospice locations accepts all hospice appropriate

patient referrals and accepts all patients without regard to race, color,

national origin, disability, age or ability to pay for admission, treatment

or participation in its hospice programs, services, activities or

employment. The parent company indicates that it has historically

provided three or four percent of its volume to the Medicaid population.

The applicant notes that the financial schedules in CON application

#10141 provide for 4.0 percent Medicaid and 2.0 percent

charity/indigent.

Hospice of Marion County, Inc. (CON #10142) indicates that it has a

history of providing health services to all patients that require hospice

care without regard to age, sex, race, ethnic group, diagnosis or ability to

pay. The applicant notes that it provided approximately $903,000 in

charity care to its hospice patients in fiscal year 2009. HMC commits to

use the profits of the Thrift Store, located in The Villages, to support non-

reimbursed programs and charity care in Hospice Service Area 3E. The

applicant provides the projected payer mix for the proposed program for

the first two years of operation. See the table below.


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Hospice of Marion County, Inc.

Projected Patient Days by Payer Type Years One and Year Two of Operation

Medicare

Medicaid

3rd Party Insurance

Self-Pay/ Other

Total

Year 1 6,437 408 215 100 7,160

Year 2 14,332 909 478 223 15,943

% of Total 89.9% 5.7% 3.0% 1.4% 100% Source: CON application #10142, page 154.

The applicant maintains that the projected financial forecasts, including

Medicaid and charity care, demonstrates the applicants commitment to

the provision of hospice services to any terminally ill patient, regardless

of ability to pay.

VITAS Healthcare Corporation of Florida (CON #10144) states that it

has a long history of providing services to Medicaid and medically

indigent patients and proposes to provide services to these patients in

Subdistrict 3E. The applicant states that it has a history of meeting

projected commitments to Medicaid and charity care patients, citing its

results from Subdistrict 4A where it projected 4.9 percent to Medicaid

patients but in the first year of operation 7.0 percent of all admissions

were Medicaid patients.

The applicant indicates that it annually provides one percent or more of

revenues in charity care—in FY 2011 this amount exceeded $4.5 million.

VITAS projects Medicaid patients will be 4.5 percent and self-pay/charity

care patients 1.1 percent of total annual patient days in years one and

two, respectively. F. SUMMARY

A fixed need pool was published for a new hospice program in Hospice

Service Area 3E, Lake and Sumter Counties. Compassionate Care Hospice of Lake and Sumter, Inc.

(CON #10140), a for-profit corporation proposes the establishment of a

new hospice program in Hospice Service Area 3E. The applicant is

proposing total project costs of $142,965 with year one operating costs of

$1,348,681 and year two costs of $3,102,696.

Compassionate Care proposes seven conditions. See pages 10 and 11 for

an in-depth description of the applicant’s proposed conditions.


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Harbor Light Hospice of Florida, Inc. (CON #10141), a for-profit

corporation proposes to establish a new hospice program in Hospice

Service Area 3E. Harbor Light is proposing total project costs of

$176,460 with year one operating costs of $805,148 and year two costs

of $2,134,559.

Harbor Light proposes 15 conditions. See pages 12-14 for an in-depth

description of the applicant’s proposed conditions.

Hospice of Marion County, Inc. (CON #10142), a not-for-profit

corporation, proposes the establishment of new hospice program in

Hospice Service Area 3E. HMC is proposing total project costs of

$292,179 with year one operating costs of $1,746,402 and year two costs

of $3,100,487.

HMC proposes 10 conditions. See pages 14 and 15 for an in-depth


VITAS Healthcare Corporation of Florida (CON #10144), a for-profit

entity, proposes the establishment of a new hospice program in Hospice

Service Area 3E, Lake and Sumter Counties. VHCF is proposing total

project costs of $881,036 with year one operating costs of $2,223,926

and year two costs of $4,708,316.

VHCF is proposing 23 conditions. See pages 15-17 for an in-depth


Need/Access:

Each applicant is responding to published need for a new hospice

program. Each applicant states that there is unmet need in Lake and

Sumter Counties, which ranged from access issues for minority

populations including Hispanics and African-Americans, Veterans,

hearing-impaired populations, the pediatric population, cardiac patients,

patients in nursing homes, to cancer patients under the age of 65 years,

cancer patients over the age of 65 years, non-cancer patients under the

age of 65 years and non-cancer patients over the age of 65 years not

having proper access to hospice services.

All applicants provided statistical data of underserved minority

populations in Hospice Service Area 3E; however, none document that

hospice care to minority residents is not available or accessible.


121

All co-batched applicants provided evidence that they have local support

for their proposals to enter the service area. All applicants provided

letters of support from hospitals, skilled nursing facilities, continuing

care retirement communities or assisted living facilities within the

hospice service area.

All 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 Lake and Sumter

Counties.

The Agency’s need methodology that resulted in published need for a new

program in Hospice Service Area 3E showed the projected number of

admissions minus the current number of admissions for the July 2013

planning horizon as 423. VHCF proposed the largest program to address

this published need while HMC proposed admission numbers closest to

the projected need:

Total Projected Admissions By Applicant

for Years One and Two CON # Applicant Year One Year Two Both Years

10140 Compassionate Care 157 366 523

10141 Harbor Light 73 204 277

10142 HMC 179 306 485

10144 VHCF 214 423 637

Source: CON application #’s 10140, 10141, 10142 and 10144.

Quality of Care:

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

As current providers of hospice services in Florida, HMC and VHCF

participated in the voluntary reporting on the Florida Health Finder,

Hospice Provider Family Satisfaction Survey; Compassionate Care, who

is also a current provider of hospice services in Florida, did not

participate.

Agency records indicate that VHCF has four substantiated complaints for

the three-year period ending June 26, 2012. Compassionate Care had

one substantiated complaint since licensure on February 22, 2011.

Hospice of Marion County, Inc. had no substantiated complaints for the

three-year period ending June 26, 2012.


122

Financial Feasibility/Availability of Funds: Compassionate Care Hospice of Lake and Sumter, Inc.

(CON #10140): Without results from operations, an analysis of the short

and long-term strength of the applicant cannot be made. Compassionate

Care’s ultimate parent provided June 11, 2012 letters stating all $2

million of its line of credit is still available. Funding for this project is in

question. However, assuming the applicant will be able to acquire

funding for start-up and working capital, this project appears to be

financially feasible.

Harbor Light Hospice of Florida, Inc. (CON #10141): Without results

from operations, an analysis of the short and long-term strength of the

applicant cannot be made. Funding for this project is in question.

However, assuming the applicant will be able to acquire funding for

start-up and working capital, this project appears to be financially

feasible.

Hospice of Marion County, Inc. (CON #10142): The applicant has an

adequate short-term and long-term position. Funding for this project

appears to be financially feasible, although this is dependent upon the

source of the “other” operating revenue that was not identified in the

applicant’s financial schedules.


applicant has an adequate short-term and strong long-term position.

Funding for this project appears to be financially feasible.

Medicaid/Charity Care: Compassionate Care Hospice of Lake and Sumter, Inc.

(CON #10140): Schedule 7 shows 1.3 percent of total annual patient

days for self-pay/charity care in years one and two of operations.

Compassionate Care’s patient day Medicaid percentage is projected to be

3.0 percent for year one and two of operations.

Harbor Light Hospice of Florida, Inc. (CON #10141): Schedule 7

shows 2.0 percent of total annual patient days for self-pay/charity care

in years one and two of operations. Harbor Light’s patient day Medicaid

percentage is projected to be 4.0 percent for year one and two of

operations.


123

Hospice of Marion County, Inc. (CON #10142): Schedule 7 shows 1.4

percent of total annual patient days for self-pay/charity in years one and

two of operations. HMC’s patient day Medicaid percentage is projected to

be 5.7 percent for year one and two of operations.

VITAS Healthcare Corporation of Florida (CON #10144): Schedule 7

shows 1.1 percent of total annual patient days for self-pay/charity in

years one and two of operations. VHCF’s patient day Medicaid

percentage is projected to be 4.5 percent for years one and two of

operations.

G. RECOMMENDATION

Approve CON #10140 to establish a new hospice program in Hospice

Service Area 3E. The total project cost is $142,965 with year one


CONDITIONS:

1. The applicant will implement its Cardiac Connections program

immediately upon licensure. It will be made available to all eligible

residents with a qualifying cardiovascular disease. As part of this

implementation the applicant will ensure:

(a) The medical director of Compassionate Care’s Cardiac

Connections Program will be a cardiologist.

(b) The Cardiac Connections Program will have a licensed nurse

practitioner.

(c) At a minimum, Compassionate Care will hold quarterly

meetings for area cardiologists to maintain open

communications with the community cardiologists to

continue to educate them about options in end of life care for

their patients.

(d) At a minimum, Compassionate Care will coordinate with

local hospitals’ staff and/or physicians on a monthly basis to

review the Cardiac Connections Program and how it may be

benefiting both the hospital and the patient in terms of

reduction in readmission rates, program success and other

measure to be determined.

(e) Cardiac Connection Program patients will receive daily

communication from Compassionate Care staff either via an

in-person visit, or by telephone if an in-person visit is not

scheduled on a particular day.


124

(f) All Cardiac Connections Program patients will have a

Cardiac Comfort Kit with them in their home.

(g) Compassionate Care will, in its an annual condition

compliance report to the Agency for Health Care

Administration, address how hospital readmissions for heart

failure have decreased in the subdistrict relative to the

Compassionate Care Hospice of Lake and Sumter cardiac

admissions.

2. Compassionate Care Hospice Group, Ltd. will implement its

Pathways to Compassion Program immediately upon licensure of

Compassionate Care Hospice of Lake and Sumter, which will be

made available to all eligible Lake and Sumter County residents.

3. Compassionate Care will implement its Veterans Outreach

Program immediately upon licensure as detailed within CON

application #10140.

4. Compassionate Care will provide a home health aide ratio above

NHPCO guidelines at an average of 10 hours per patient per week.

5. Compassionate Care will not participate in fundraising activities in

Subdistrict 3E.

6. Compassionate Care will not build or operate freestanding hospice

facilities in Subdistrict 3E.

Deny CON Numbers 10141, 10142 and 10144.


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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration

adopted the recommendation contained herein and released the State Agency

Action Report.

DATE:

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

Jeffrey N. Gregg Director, Florida Center for Health Information and Policy Analysis

state agency action report - the agency for...

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