STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED

Transcription

1 STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number HealthSouth of Fort Lauderdale, Limited Partnership/CON #9560 d/b/a HealthSouth Sunrise Rehabilitation Hospital HealthSouth Corporation One HealthSouth Parkway Birmingham, Alabama Authorized Representative: Loree Skelton (205) St. John's Rehabilitation Hospital & Nursing Ctr., Inc./CON #9561 d/b/a St. John's Rehabilitation Hospital & Nursing Center, f/k/a Broward County Nursing Home, Inc. 502 East Park Avenue Tallahassee, Florida Authorized Representative: Paul H. Amundsen, Esq. (850) Tenet HealthSystems Hospitals, Inc./CON #9562 d/b/a Hollywood Medical Center 500 West Cypress Creek Road, Suite 370 Fort Lauderdale, Florida Authorized Representative: Robert Greene (954) South Broward Hospital District/CON #9563 d/b/a Memorial Regional Hospital 3501 Johnson Street Hollywood, Florida Authorized Representative: Jon D. Bandes, Director of Planning (954)

2 2. Service District/Subdistrict District 10, Broward County B. PUBLIC HEARING Although no public hearing was requested, the applicants did submit letters of support for their respective projects as presented below: HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) submitted seven (7) letters of support for the proposed project to add 11 beds to its existing 116-bed HealthSouth Sunrise Rehabilitation Hospital. Letters of support were received from two case managers, one at University Hospital and Medical Center in Tamarac and the other from Westside Regional Medical Center in Plantation. Other letters of support were received from the Mayor of Sunrise, a local attorney with clients as patients at the hospital, the president of the Sunrise Chamber of Commerce, the Director of Community Services at the Broward County Property Appraisers Office and a seven-group physicians office, who has admitted to the facility for over 16 years. The physicians group and the case manager at Westside Regional Medical Center made reference to delays in admissions because of bed availability problems. All of the letters are of general support, not offering any numeric data or unique circumstances supporting the project. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) submitted ten letters of support in its effort to add 11 (the applicant also submitted a partial request for five) CMR beds to the 20- bed comprehensive medical rehabilitation program at its facility. Six of the letters were from physicians who admit patients to the facility and the theme of their letters acknowledges the quality and compassionate care provided patients at the facility. One physician even had a member of his own family at the facility for three years and said that she received excellent care. Another physician praised the facility with this comment: "With its combination of a rehabilitation hospital, nursing home, and assisted living facility; SJRH offers a continuum of care that is unparalleled in our geographic region." Other letters were from: a clinical neuropsychologist; a utilization review coordinator with BCBS/Health Options; the facility Chaplin, who is also a recipient of rehabilitative services at the facility; and a Workers' Compensation rehabilitation nurse case manager. As with the physicians, these individuals expressed support for the project and confirmation of the quality, compassionate care provided at St. John's Rehabilitation Hospital and Nursing Center. 2

3 Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center submitted five letters from area physicians supporting the hospital's effort to increase the CMR beds by 11 (Tenet also submitted a five-bed partial request). All letters support need for additional beds and speak to the quality and effectiveness of the staff. Most of the practitioners appear to be internist, cardiologist, or family medicine physicians. One of the physicians is an urologist. All of the letters are of general support, not offering any numeric data or unique circumstances supporting the project. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital submitted 20 letters of support for its proposed six-bed addition to its comprehensive medical rehabilitation program. All 20 of the letters, 18 by physicians and two by HMO representatives, voice the need for a dedicated pediatric CMR program in Broward County since there currently are none. Some of the physician letters note that the applicant provides the only Pediatric Trauma Center in Broward County and that the Joe DiMaggio Children's Hospital treats numerous patients with traumatic brain injury, spinal cord injury, orthopedic emergencies and neurological disorders. These patients often require rehabilitative services. Other physicians speak to the quality of care provided and the dedication by staff to assure highly specialized, compassionate care to children. All of the letters are of general support, not offering any numeric data or unique circumstances supporting the project. C. PROJECT SUMMARY HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital is part of a proprietary hospital system to the extent that HealthSouth Corporation controls 99 percent of the partnership. HealthSouth Sunrise Rehabilitation Hospital, a 116-bed Class III specialty rehabilitation hospital, is located at 4399 Nob Hill Road in Sunrise, District 10. The applicant currently provides adult inpatient comprehensive medical rehabilitation (CMR) services as well as outpatient CMR services. The applicant is proposing the addition of 11 CMR beds to its existing 116 and 10 CON approved (#9262) CMR beds for a 137-bed facility. As a condition of approval, the applicant proposes to provide three (3.0) percent of the annual patient days for the proposed 11-bed addition to Medicaid patients and one (1.0) percent of these days to indigent/charity patients. There is an existing condition at the facility pursuant to the approval of CON #9262 that carries a combined Medicaid/charity 3

4 condition of 0.23 percent of total annual patient days in the 126 currently licensed beds. A blending of the proposed three (3.0) percent Medicaid and one (1.0) percent charity condition would result in a Medicaid and charity condition of 0.56 percent in the 137 licensed and approved beds. The total project cost is estimated at $1,268,410. Construction costs are projected to be $742,500 to renovate 8,180 GSF of existing space. No new space is indicated for the project. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center, (f/k/a Broward County Nursing Home, Inc.) is a private, not-for-profit Florida corporation established under the sponsorship of the Archdiocese of Miami, operates a Class III, 20-bed comprehensive medical rehabilitation specialty hospital (CMR) and a 160-bed skilled nursing facility at 3075 N.W. 35 th Avenue, Lauderdale Lakes in Broward County. The applicant seeks approval for the addition of 11 CMR beds, or as an alternative, to add five (5) CMR beds (CON #9561P) to its existing 20-bed program. The 11-bed addition will be accomplished through the renovation 3,469 GSF of space at a construction cost of $54,300. The total cost of the proposed 11-bed project is estimated to be $106,500. The alternative project for five (5) CMR beds (#9561P) proposes to renovate 1,446 GSF at a cost of $11,700. The total cost of this partial project is expected to be $49,660. According to the Certificate of Need Predicated on Conditions page, the applicant is proposing a minimum of three percent of its total annual patient days to Medicaid/charity care patients. St. John s Rehabilitation Hospital currently has no existing conditions. Therefore blending the proposed three percent for 11 beds with the 20 existing beds would result in a combined Medicaid/charity condition of 1.06 percent for the 31 CMR beds. If the five-bed project is approved, a blending of the proposed condition with the existing 20 beds will result in a 0.6 percent combined Medicaid/charity condition. 4

5 Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center, is a wholly owned subsidiary of Tenet Healthcare Corporation, a publicly traded company that owns and operates hospitals, health care facilities and nursing homes throughout the United States. Hollywood Medical Center, located at 3600 Washington St. in Hollywood, is a Class I, 324-bed for-profit general acute care hospital that includes a 33-bed comprehensive medical rehabilitation program. The applicant is seeking to add 11 CMR beds to its existing program, or as an alternative, to add five (5) CMR beds (CON #9562P). The 11-bed addition will be accomplished through the renovation 6,000 GSF of space at a renovation/construction cost of $490,000. The total cost of the proposed 11-bed project is estimated to be $923,575. The alternative project for five (5) CMR beds (CON #9562P) proposes to renovate 1,240 GSF at a cost of $60,000. The total cost of this partial project is expected to be $248,075. According to the Certificate of Need Predicated on Conditions page, the applicant is proposing a minimum of three percent of its total annual patient days to charity care patients in either the 44 or 38 CMR beds. There is an existing condition of two percent Medicaid and charity assigned to the 33 licensed CMR beds. The applicant has consistently complied with this condition. Assuming approval of the proposed 11-bed project, a blending of the proposed three percent condition with the existing 33 beds at two percent combined Medicaid/charity would result in a new combined condition of 2.25 percent for the 44 beds. If the fivebed project is approved, a blending of the proposed five beds at three percent with the existing 33 beds at two percent will result in a new combined condition of 2.13 percent Medicaid/charity on the 38-bed project. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital was created by legislative enactment, is governed by a seven-member Board of Commissioners and possesses taxing authority. Memorial Regional Hospital is a 684-bed Class I general acute care hospital which includes: 71 adult psychiatric beds; 11 adult substance abuse beds; 10 child/adolescent psychiatric beds; 22 Level II NICU beds; 19 Level III NICU beds, a 26-bed hospital based skilled nursing unit and 36 comprehensive medical rehabilitation beds. The applicant proposes to add six comprehensive medical rehabilitation beds (CMR) beds to the Joe DiMaggio Children's Hospital, a "hospital without walls" located within Memorial Regional Hospital. The proposed addition of the six-bed pediatric rehabilitation unit will be located in 3,000 square feet of renovated space on the fourth floor of Memorial Regional Hospital. The 5

6 renovation cost is projected at $525,000 and the total project cost is expected to be $789,150. According to the Certificate of Need Predicated on Conditions page, the applicant is proposing 15 percent of annual patient days associated with the six pediatric CMR beds, be dedicated to Medicaid patients. In addition, three percent of annual gross revenues for the six-bed unit will be provided as indigent care. There is an existing condition at the facility pursuant to CON #8048 that carries a four percent Medicaid condition and a 3.5 percent charity condition on the 36 licensed CMR beds. A blending of the existing and proposed conditions would result in a new Medicaid condition of 5.57 on the 42 licensed and a 3.43 percent condition on these same beds for charity patients. D. REVIEW PROCEDURE The evaluation process is structured by the certificate of need review criteria found in Section , Florida Statutes, rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code, and local health plans. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by evaluating the responses and data provided in the application, and independent information gathered by the reviewer. Applications are analyzed to identify strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district (subdistrict), applications are comparatively reviewed to determine which applicant(s) best meets the review criteria. Rule 59C-1.010(2) (b), Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the Certification of the applicant. As part of the fact-finding, the consultant, Ed Carter, analyzed the application with consultation from the financial analyst, John Williamson, who reviewed the financial data and architect Joel Hill, who evaluated the architecturals and the schematic drawings. 6

7 E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicate the level of conformity of the proposed project(s) with the review criteria and application content requirements found in Sections , and ; applicable rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code; and Local Health Plans. 1. Fixed Need Pool a. Does the project proposed respond to need as published by a fixed need pool? Chapter 59C and rule 59C In Volume 28, Number 4, dated January 25, 2002 on page 375 of the Florida Administrative Weekly, a fixed need pool projection of 11 beds was published for comprehensive medical rehabilitation beds in District 10 for the July 2007 planning horizon. District 10 has 283 licensed and 19 CON approved comprehensive medical rehabilitation beds. The comprehensive medical rehabilitation beds in District 10 experienced an occupancy rate of percent during the period July 2000 through June CMR Occupancy Rates District 10 Facility County Licensed Beds HealthSouth Sunrise Rehabilitation Hospital. Broward % Hollywood Medical Center Broward % Holy Cross Hospital Broward % Memorial Regional Hospital Broward % North Broward Medical Center Broward % St. John's Rehabilitation Hospital & Nursing Ctr. Broward % Average % Source: Florida Hospital Bed and Service Utilization by District - January 25, 2002 Occupancy % (07/00-06/01) All four co-batched applicants are individually seeking beds within the fixed need projection of 11 CMR beds for District 10. One of the cobatched applicants is seeking to establish fewer than the 11 beds published as needed in the district. Memorial Regional Hospital seeks to add six CMR beds while the other three intend to add eleven beds to their respective existing CMR programs. Two of these applicants, St. John's Rehabilitation Hospital and Nursing Center and Tenet/Hollywood Medical Center, propose alternative five-bed partial projects. 7

8 2. Local Health Plan Preferences Is need for the project proposed supported by the applicable district plan? ss (1)(a), Florida Statutes and Ch. 59C-1.039, Florida Administrative Code. The District 10 October 2000 CON Allocation Factors Report does not provide preferences in the review of applications pertaining to comprehensive medical rehabilitation beds. The Broward Regional Health Planning Council does include the following general provision for hospitals in its CON preferences: (1) Priority should be given to those applicants that have a history of and clear expression of intent to provide services to the indigent. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital proposes to provide indigent/charity care equal to at least one percent of patient days and three percent of patient days to Medicaid patients associated with the proposed 11-bed addition. Based on information reported to AHCA, this applicant provided 1.8 percent Medicaid and no charity care for the FY 2000 reporting period. The applicant has a policy for admitting financial hardship discount and charity patients that requires the completion of disclosure forms prior to the patient receiving clinical services. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center, is part of the extensive Catholic Health Services (CHS) network which provides a broad continuum of health care, residential, community support and advocacy services to the elderly, the poor and the needy throughout the Archdiocese of Miami, which includes Broward County. Indigent patients who are candidates for rehabilitation services at St. John's will continue to be assessed on a case-by case basis and approval for an appropriate placement will be sought from CHS. The applicant agrees to be condition upon approval of the proposed 11 CMR beds (or five-bed partial) for a minimum of three percent of the CMR program's total patient days to a combination of Medicaid and/or indigent patients. Based on its current payor mix in the CMR hospital, the applicant projects utilization that includes about 4.0 percent traditional Medicaid patient days and about 1.2 percent self-pay days, which it states may include a few charity care days. Based on 8

9 information reported to AHCA, this applicant provided 8.1 percent Medicaid and no charity care for the FY 2000 reporting period. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center is proposing a minimum of three percent of its total annual patient days to charity care patients. The applicant has consistently complied with its current two percent Medicaid and charity condition for the 33 licensed CMR beds. The applicant explains that historically it has not denied access to any party regardless of ability to pay, however the proximity of its hospital to one of the taxing district hospitals that provides CMR services, is why most of the indigent patients requiring this service go to the taxing district hospitals. Hollywood Medical Center reported Medicaid admissions for 1999 at 3.8 percent, for 2000 at 3.3 percent and for 2001 at 3.6 percent. No specific charity admissions were reported. Based on information reported to AHCA, this applicant provided 3.2 percent Medicaid and 0.5 percent charity care for the FY 2000 reporting period. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital is proposing 15 percent of annual patient days associated with the six pediatric CMR beds, be dedicated to Medicaid patients. In addition, three percent of annual gross revenues for the six-bed unit will be provided as indigent care. For the years 1998 through 2000 the applicant consistently complied with its condition to provide four percent of 36 CMR beds to Medicaid patients and 3.5 percent to charity. According to the applicant, currently, the South Broward Hospital District serves all patients in Broward County, including 108,000 who do not have health insurance. The South Broward District is the safety net provider in the south Broward service area and therefore carries the burden of significantly higher Medicaid and uncompensated care. In the last three years, the amount of revenue associated with the provision of care to medically indigent patients has increased by over 30 percent, according to the applicant. Based on information reported to AHCA, this applicant provided 13.0 percent Medicaid and 6.6 percent charity care for the FY 2000 reporting period. 9

10 3. Agency Rule Criteria Please indicate how each applicable preference for the type of service proposed is met. Refer to Chapter 59C-1.039, Florida Administrative Code, for applicable preferences. a. Section 59C-1.039(3) & (4), Florida Administrative Code: General Provisions and Required Staffing and Services General Provisions: 1. Service Location. The CMR inpatient services regulated under this rule may be provided in a hospital licensed as a general hospital or licensed as a specialty hospital. Two of the competing applicants for CMR beds are classified as Class III Specialty Hospitals and the other two are Class I General Acute Care Hospitals with designated CMR units. See Project Summary for facility license designation. 2. Separately Organized Units. CMR inpatient services shall be provided in one or more separately organized units within a general hospital or specialty hospital. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital is an existing 116-bed Class III Specialty Hospital governed under Chapter 395, Florida Statutes. The applicant is approved for 10 additional CMR beds, which are expected to become operational in August 2002, bringing its licensed bed complement to 126 beds. The applicant seeks to expand the facility by 11 comprehensive medical rehabilitation beds arranged in five semi-private rooms and one private room. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center is an existing 20-bed Class III Specialty Hospital governed under Chapter 395, Florida Statutes. The facility is co-located with a 160-bed skilled nursing home. The applicant seeks to add 11 CMR beds or a partial five-bed project as an alternative. According to the architectural review, the bed addition will be accomplished in part through the conversion of private rooms to semi-private use. 10

11 Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center proposes to add 11 CMR beds to an existing 33-bed CMR unit within a 324-bed general acute care hospital. The applicant is requesting consideration of a partial five-bed project as an alternative to the 11 beds originally requested. Space for the addition beds will be gained from renovation/conversion of existing areas. For details see Architect's Report in 4. h. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital is a 684-bed Class I General Acute Care Hospital with a 36-bed CMR unit. The applicant seeks to add six CMR beds to the Joe DiMaggio Children's Hospital on the fourth floor. Though physically separated from the existing 36-bed CMR unit on the seventh floor of the hospital, the applicant states that the pediatric rehabilitation unit at Joe DiMaggio Children's Hospital will not be independent of the existing rehabilitation expertise at the hospital and will operate as a satellite of the adult unit. The six-bed unit will consist of two semi-private rooms and two private rooms. 3. Minimum Number of Beds. A general hospital providing comprehensive medical rehabilitation inpatient services should normally have a minimum of 20 comprehensive medical rehabilitation inpatient beds. A specialty hospital providing CMR inpatient services shall have a minimum of 60 CMR inpatient beds. Of the four co-batched applicants, only St. John's Rehabilitation Hospital & Nursing Center has fewer beds than required by this element of the Rule. Pursuant to a Joint Stipulation in DOAH Case Number , St. John's Nursing and Rehabilitation Center was issued CON #2183 (Amended) authorizing the applicant to "Convert 20 skilled nursing home beds to comprehensive inpatient physical rehabilitation beds". The 20-bed "facility" was licensed (License #1528) under Chapter 395, Part I, Florida Statutes on November 1, 1984 as Broward County Nursing Home, Inc. d/b/a St. John's Nursing & Rehabilitation Hospital. Under this license the licensee was authorized to operate a 20-bed Special Rehabilitation Hospital. 11

12 4. Conformance with Criteria for Approval. A CON for the establishment of new CMR inpatient services, the construction or addition of new CMR inpatient beds, or the conversion of licensed hospital acute care beds to CMR inpatient beds shall not normally be approved unless the applicant meets the applicable review criteria in Section , Florida Statutes, and the standards of need determination criteria set forth in this rule. For all co-batched applicants, see response to E.1.a., above and E.4.a., below. 5. Medicare and Medicaid Participation. An applicant proposing to increase the number of licensed CMR inpatient beds at its facility shall participate in the Medicare and Medicaid programs. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital is a participating provider in the Medicare and Medicaid programs and intends to maintain this status for the proposed 11 new CMR beds. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center, is a participating provider in the Medicare and Medicaid programs and intends to maintain this status for the proposed 11 new (or five partial) CMR beds. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center is a current participant in the Medicare and Medicaid programs and intends to maintain this status for the proposed 11 new (or five partial) CMR beds. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital is a participating provider in the Medicare and Medicaid programs and intends to maintain this status for the proposed six new CMR beds. b. Required Staffing and Services. 1. Director of Rehabilitation. CMR inpatient services must be provided under the medical director of rehabilitation who is a board-certified or board-eligible physiatrist and has had at least two years of experience in the medical management of inpatients requiring rehabilitation services. 12

13 HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital has as its medical director, Dr. Scott David Tannenbaum a board-certified physiatrist, who has served in this position since November Dr. Tannenbaum has more than 11 years of experience in the medical management op patients requiring CMR services. In addition to Dr. Tannenbaum, Dr. Lauren Lerner is board-certified in physical medicine and rehabilitation and is the medical director of the CARF-accredited spinal cord and brain injury programs at the hospital. Medical director of Sunrise's CARF-accredited comprehensive pain management program is Dr. Matthew Deutscher, board-certified in physical medicine and rehabilitation. Dr. Deutscher has more than 12 years of experience in the medical management of patients requiring rehabilitation services. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center has as its medical director Dr. Veronica Gipps, who is boardcertified in physical medicine and rehabilitation, and serves as a diplomat to the American Board of Physical Medicine and Rehabilitation. Dr. Gipps has been in practice for 10 years and affiliated with St. John's Rehabilitation Hospital for seven of those years. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center has as its medical director Ronald Barton Tolchin, D.O., FAAPM&R, a physiatrist who is boardcertified by and a fellow of the American Board of Physical Medicine and Rehabilitation. Dr. Tolchin's University appointments include Nova Southeastern University, University of Miami Medical School and University of Medicine and Dentistry of New Jersey. He maintains his clinical instructor positions at Nova and University of Miami and also holds the Assistant Professor and Chairman position in Nova's Department of Family Medicine, Department of Physical Medicine and Rehabilitation. Dr. Tolchin is also on the staff of Mount Sinai Medical Center, Aventura Hospital and Medical Center, North Shore Medical Center and VA Medical Center. 13

14 South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital has two board-certified physiatrists on staff that will be available to patients of the proposed six-bed addition of the dedicated pediatric rehabilitation beds in the Joe DiMaggio Children's Hospital. Dr. Alan Novick is currently the rehabilitation medical director at Memorial Regional Hospital. Prior to being appointed medical director in July 2001 of all rehabilitation programs at Memorial, Dr. Novick served as medical director for Occupational Rehabilitation at the Hospital from 1994 to Dr. Esperanza Vargas-Posada is the current medical director of Pediatric Rehabilitation and Early Intervention and Development Programs at the Joe DiMaggio Children's Hospital. Dr. Vargas- Posada is board-certified by the American Board of Physical Medicine and Rehabilitation as a physiatrist and is licensed to practice medicine in both New York and Florida. Dr. Vargas- Posadas' career spans more than 30 years and includes positions such as medical director for various pediatric rehabilitation units including West Gables Rehabilitation Hospital in Miami, the Joe DiMaggio Children's Hospital at Memorial Regional Hospital in Hollywood, and as Attending Physiatrist at Blythedale Children's Hospital and New York Medical College, both in New York according to the vitae, included in the application. The applicant states that Dr. Vargas' experience and training in the highly specialized field of pediatric rehabilitation medicine is evidence that she is a very qualified choice to be Medical Director of both Pediatric Rehabilitation and the Early Intervention and Development Programs at the Joe DiMaggio Children's Hospital. 2. Other Required Services. In addition to the physician services, CMR inpatient services shall include at least the following services provided by qualified personnel: 1. Rehabilitation nursing 2. Physical therapy 3. Occupational therapy 4. Speech therapy 5. Social services 6. Psychological services 7. Orthotic and prosthetic services 14

15 HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital is an existing provider of CMR services and provides a range of services that meet or exceed the minimum requirements and intends to increase staffing to continue this level of care in the proposed new beds. Orthotic and prosthetic services will be provided through external vendors. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center, is an existing provider of CMR services and provides a range of services that meet or exceed the minimum requirements and intends to increase staffing to continue this level of care in the proposed new beds. Orthotic and prosthetic services will be provided through various external vendors. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center is an existing provider of CMR services and provides a range of services that meet or exceed the minimum requirements and intends to increase staffing to continue this level of care in the proposed new beds. Psychological services and orthotics/prosthetics services will be provided via contractual relationships with independent parties. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital is an existing provider of CMR services and provides a range of services that meet or exceed the minimum requirements and intends to increase staffing to continue this level of care in the proposed new beds. Therapists are trained in the use of orthotic and prosthetic devices and assist in patient fittings and the use of these devices. While the applicant did not specifically state, it is presumed that a contract exists with outside vendors to provide orthotic/prosthetic devices to patients in the hospital. Very few facilities are set-up to create these devices inhouse. c. Section 59C-1.039(5)(g), Florida Administrative Code, states that priority considerations for CMR inpatient services will be given to applicants who: (1) are a disproportionate share hospital; (2) are proposing to service Medicaid-eligible persons; and, (3) are a designated trauma center. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital is not a disproportionate share hospital, nor is it a designated trauma center. A 15

16 blending of the proposed three (3.0) percent Medicaid condition would result in a combined percent condition in the 127 licensed and approved beds. In addition to the Medicaid condition, a blended indigent/charity condition would result in percent of total annual patient days to indigent/charity patients in the 127 licensed and approved beds. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center is not a disproportionate share hospital, nor is it a designated trauma center. There are no existing CON conditions relative to CMR services at the facility. The applicant is proposing a minimum of three percent of its total annual patient days to Medicaid/charity patients. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center is not a disproportionate share hospital, nor is it a designated trauma center. There is an existing condition of two percent Medicaid and charity assigned to the 33 licensed CMR beds and the applicant has consistently complied with this condition. In this application the applicant is proposing a minimum of three percent of its total annual patient days to charity care patients only. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital is a designated Medicaid Disproportionate Share Provider for State Fiscal Year It is also a Level I trauma center for adults and pediatric patients. The pediatric emergency department and trauma center are provided through the Joe DiMaggio Children's Hospital at Memorial Regional Hospital and staffed 24 hours per day, seven days per week with pediatric emergency physicians and pediatric nurses who specialize in emergency medicine. There is an existing condition at the facility pursuant to CON #8048 that carries a four percent Medicaid condition and a 3.5 percent charity condition on the 36 licensed CMR beds. In this application the applicant is proposing 15 percent of annual patient days associated with the proposed six pediatric CMR beds be dedicated to Medicaid patients. In addition, three percent of annual gross revenues for the six-bed unit will be provided as indigent care. A blending of the existing and proposed conditions would result in a new Medicaid condition of 5.57 on the 42 licensed and presumed approved CMR beds and a 3.43 percent condition on these same beds for charity patients. 16

17 d. 59C-1.039(6), Florida Administrative Code, Access Standard Comprehensive medical rehabilitation inpatient services should be available within a maximum ground travel time of two hours under average travel conditions for at least 90 percent of the district s total population. Inpatient CMR services in the district are available within a two hours drive time for at least 90 percent of the district s total population. e. 59C-1.039(7), Florida Administrative Code, Quality of Care: CMR inpatient services shall comply with agency standards for program licensure described in Section 59A-3, Florida Administrative Code. Applicants who submit an application that is consistent with the agency licensure standards are deemed to be in compliance with this provision. Applicants proposing to add beds to a licensed CMR inpatient service have received full Medicare certification as a rehabilitation hospital. All four of the existing CMR providers are Medicare providers of CMR services. Refer to Section 4. b. below. f. 59C-1.039(8), Florida Administrative Code, Services Description: An applicant for comprehensive medical rehabilitation inpatient service shall provide a detailed program description in its certificate of need application including: 1. Age groups to be served. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital indicates it serves patients aged 14 and up, however over 72 percent of the patients discharged in 2000 were Medicare patients. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center stated that discharge data revealed that 75 percent of the patients discharged in CY 2001 were 65 and older, "leaving a significant portion (25 percent) who were younger adults." The applicant anticipates that it will continue to draw a similar blend of elderly and younger patients in the expanded CMR program, since it will continue to offer the same services plus aquatic rehabilitation, transitional ADL training, and expanded dining/socialization programs. 17

18 Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center reported the average age of patients, during the 12 months ending June 30, 2001, in the CMR unit was 75.9 and the median age was 79 years of age with the youngest being 24 and the oldest 100 years of age. Persons 65 years of age and older comprise 81.1 percent of admissions to the CMR unit and the applicant does not expect the age dispersion to change with the expansion of the 33-bed CMR unit by 11 (or five) beds. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital currently operates a 36-bed CMR unit dedicated to adult patients. The proposed six-bed addition seeks to establish a dedicated CMR unit for pediatric patients within the Joe DiMaggio Children's Hospital at Memorial Regional Hospital. The facility currently provides highly specialized medical care to all children and adolescents ages 0 to 18. Adolescent cases are placed in Joe DiMaggio Children's Hospital or Memorial Regional Hospital on a case-by-case basis. The applicant did not provide a breakdown of admissions or discharges by age group in response to this criterion. However, elsewhere in the application it is revealed that 41 percent of CMR discharges for 2001 were Medicare patients. The applicant has the lowest Medicare discharge rate for CMR patients among the co-batched applicants. While not specifically revealed, this could support the need for pediatric/adolescent beds requested by the applicant with 59 percent of CMR discharges presumably under 65 years of age. 2. Specialty inpatient rehabilitation services to be provided, if any (e.g. spinal cord injury; brain injury). HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital listed six programs offered at its facility that are CARF accredited. The applicant did not identify any new programs as a result of the proposed 11 CMR bed addition. Existing programs offered by the applicant include: 1. Comprehensive Integrated Inpatient Rehabilitation Prog. 2. Brain Injury Program 3. Spinal Cord Rehabilitation System of Care 4. Comprehensive Pain Management Program (Inpt. & Outpt.) 5. Work-specific Occupational Rehabilitation Program 6. Home and Community-Based Rehabilitation Program 18

19 Along with each of the CARF-accredited programs the applicant offers the following programs in both inpatient and outpatient settings: > Orthopedic Rehabilitation > Lymphedema Management > Stroke Rehabilitation > Outpatient Pediatric Rehab > Amputee Rehabilitation > Disabled Driver Program > Hand Rehabilitation > Outpatient Rehabilitation > Pulmonary Rehabilitation > Assisted Technology > Aquatics Program > Outpatient Cardiac Rehab > Day Rehab/Treatment Prog. > Women's Health Rehab Prog. > Neurological Rehab Prog. > The Bridge > Complementary Health Program The applicant described each of the programs listed above in its application. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center currently offers the following medical rehabilitation programs: > Stroke Rehabilitation > Traumatic Brain Injury Program > Neurological Rehabilitation: + Spinal cord injury + Multiple sclerosis + Peripheral neuropathy + AIDS patients with neurological involvement + Parkinson's disease + Spasticity management + Other neurological disorders > Orthopedic Rehabilitation + Fast track joint rehabilitation program + Total joint rehabilitation + Multiple trauma > Amputee Rehabilitation > Arthritis Rehabilitation > Outpatient rehabilitation/follow-up services In addition to the above programs/services, the applicant expects to provide the following programs when the existing CMR unit relocates to renovated areas in the St. Joseph's Residence this fall. The new programs will include: 19

20 > Aquatic rehabilitation programs > Transitional ADL living/training programs > Community dining and socialization The applicant states that it is applying for CARF accreditation. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center CMR program is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) and includes patients with the following diagnoses: amputation, brain injury, complex orthopedic injuries, congenital deformities, fractured hip repair, Guillain Barre, multiple sclerosis, multiple trauma, muscular dystrophy, neurological disorder, Parkinson's disease, polyarthritis including rheumatoid arthritis, pulmonary diseases, spinal cord injuries, stroke and total joint replacements. The applicant did not indicate that the addition of beds would add any new services or programs at the hospital. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital offers a variety of programs for its adult rehabilitation patients that will be extended and specially tailored to include the needs of pediatric patients. These programs include: a brain injury program that is certified by the State of Florida, Department of Health, a spinal cord injury program, a variety of physical therapy programs, occupational therapy for outpatients, speech/language pathology, neuropsychology/rehabilitation psychology and an early intervention and developmental program. According to the applicant, the Early Intervention and Developmental Program is certified by the Broward County Board of County Commissioners under the Children's Services Administration Division, as an Early Intervention and Development Program provider. The applicant states that there are currently there are only two Broward County providers that offer a certified Early Intervention and Developmental Program and they are the South Broward Hospital District and the North Broward Hospital District. The Joe DiMaggio Children's Hospital Early Intervention and Developmental Program currently serves infants and toddlers age zero (0) to three (3) years who exhibit one or more risk factors for developmental delay, or slow or impaired development. The facility sees approximately 750 patients through the Early Intervention and Developmental program each year. The proposed project will provide a six-bed dedicated pediatric CMR program within the hospital. The applicant is both JCAHO and CARF accredited. 20

21 3. Proposed staffing, including qualifications of the medical director, a description of staffing appropriate for any specialty program, and a discussion of the training and experience requirements of all staff who will provide comprehensive medical rehabilitation inpatient services. All four of the co-batched applicants have existing CMR programs, fully staffed with trained, qualified professionals and a medical director. Each application contains a curriculum vitae of its qualified medical director. For a detail of the proposed staffing, see Schedule 6A in each application. 4. A plan for recruiting staff, showing expected sources of staff. All four of the co-batched applicants are established hospitals with experience in the recruitment, retention and development of staff. While none of them indicated that they expected problems in recruiting registered nurses for their proposed CMR bed additions, it is common knowledge that there is a nursing shortage in the country. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital states that it provides a complete and innovative recruitment and retention program, including "sign-up bonuses". HealthSouth Corporation has clinical affiliation agreements with more than 550 Universities and Colleges, which are available to the applicant. HealthSouth Corporation is an attractive employer, offering opportunities for career growth and relocation. HealthSouth Corporation believes in recruitment from within: therefore, any new staff openings are posted at each of the existing hospitals in Florida. The applicant did not indicate it expected a problem recruiting qualified registered nurses to fill the four new positions created by the proposed project. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center proposes to add 2.2 FTEs registered nurses for the second year if it is approved for 11 new CMR beds or 0.9 RN FTEs if approved for only five CMR beds. The applicant expects to be able to add rehab staff gradually through its routine recruitment techniques and uses Catholic Health Services to fill open positions. This will entail reviewing on-file applications from qualified candidates, advertising/interviewing for open positions, participating in school job fairs, and accessing the CHS network of manpower resources. 21

22 The applicant also expects there are staff members currently working in the ALF areas of St. Joseph's Residence who would be qualified to work in the CMR program when it relocates to that building, or interested in training to do so in the face of the reduction in ALF beds. The applicant did not indicate it expected a problem recruiting qualified registered nurses to fill the new positions created by the proposed project. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center is proposing the addition of three RN FTEs in the second year of operations, whether it is approved for 11 or five new CMR beds. The applicant expects to recruit the additional staff required for the expansion from its current pool of staff and its traditional method of staff recruitment. The applicant is a member of the South Florida Hospital and Healthcare Association, which is in the midst of developing and implementing a national campaign to recruit health care professionals to the region for placement in its member hospitals. The facility has a retention program in place that provides extensive benefits in addition to recognition and reward programs and community and employee activities. The applicant did not indicate it expected a problem recruiting qualified registered nurses to fill the new positions created by the proposed project. South Broward Hospital District (CON #9563) d/b/a Memorial Regional Hospital proposes to add 4.2 RNs to staff the six proposed CMR beds. As the second largest hospital in Broward County, the applicant has established recruitment techniques as part of its strong recruitment program: advertisements in major city newspapers, postings via the internet and the South Broward Hospital District website, and the use of a professional recruiter, are some of the tools used to recruit needed staff. The applicant believes that retention and development of clinical staff is just as crucial as recruitment and hiring of staff. Consequently the applicant has an aggressive program for continued development of staff. The applicant did not indicate it expected a problem recruiting qualified registered nurses to fill the new positions created by the proposed project. 5. Expected sources of patient referrals. HealthSouth of Fort Lauderdale, Limited Partnership (CON #9560) d/b/a HealthSouth Sunrise Rehabilitation Hospital received 3,675 patient referrals from 715 physicians during Slightly over half (54.5 percent) of these referrals were from three 22

23 Broward County hospitals: Florida Medical Center 20.2 percent (741), Westside Regional Medical Center 19.5 percent (716) and University Hospital & Medical Center with 14.8 percent (545). Another 27.3 percent (1004) referrals were classified as, "Other Facilities" by the applicant, which included patients from Palm Beach, Broward and Dade Counties. The applicant anticipates similar referral patterns in the future and projects referral sources to arise from secondary markets in north Dade County and south Palm Beach County. Furthermore, the applicant intends to target the growing Hispanic community in south Florida by soliciting large Hispanic churches, working with the local Latin Chamber of Commerce, placing ads in local Hispanic publications and through the resources of HealthSouth International marketing team and HealthSouth Puerto Rico. St. John's Rehabilitation Hospital & Nursing Center, Inc. (CON #9561) d/b/a St. John's Rehabilitation Hospital & Nursing Center already has a wide referral base which extends throughout Broward County and on into northern Miami-Dade County. The applicant cited Agency discharge data for 2001, stating that about eight percent of the facility's discharges were from Miami-Dade. The presence of 120 ALF units, 160 skilled nursing beds, and 108 HUD elderly housing units as well as Catholic Home Health Services of Broward on the applicants' campus, provides a steady stream of patients who require rehabilitation services. The applicants association with Catholic Health Services and with Catholic churches drives many referrals. In addition, the applicant has a long-lasting relationship with key area physicians who refer patients to the facility. Tenet HealthSystems Hospitals, Inc. (CON #9562) d/b/a Hollywood Medical Center experienced 92.2 percent of its admissions from hospital transfer patients for the 12-month period ending June 30, The facility has both admission and discharge relationships with the following providers: Aventura Hospital and Medical Center, Palmetto General Hospital, Parkway Regional Medical Center, Cleveland Clinic Hospital, Memorial Healthcare System, Hillcrest Nursing and Rehab, Hollywood Hills, Regents Park, Palm Gardens, Miami Jewish Home of the aged, Douglas Gardens, HCR Manor Care of Plantation, HCR Manor Care of Lauderhill, HCR Manor Care of Miami Lakes, and Carehouse of Hallandale Beach. The applicant does not expect referral patterns to change as a result of a new bed addition. 23