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 LP Pensacola, LLC/CON # Bluegrass Parkway Louisville, Kentucky Authorized Representative: John Harrison (502) Presbyterian Retirement Communities, Inc. d/b/a Westminster Oaks/CON # West Lucerne Circle Orlando, Florida Authorized Representative: Henry Keith (407) Ext. 267 PruittHealth Leon County, LLC/CON # Jeurgens Court Norcross, Georgia Authorized Representative: Neil L. Pruitt, Jr. (770) Service District/Subdistrict District 2/Subdistrict 2-4 (Leon County) B. PUBLIC HEARING A public hearing was not held or requested regarding any of the proposed projects.

2 Letters of Support LP Pensacola, LLC (CON #10246) submitted four letters of support from various members of the medical community, including Mr. Mark A. Robinson, Chief Executive Officer of Capital Regional Medical Center located in Tallahassee. Presbyterian Retirement Communities, Inc. (CON#10247) did not submit any letters of support. PruittHealth Leon County, LLC (CON #10248) submitted eight letters of support. All were form letters signed by local health care providers. C. PROJECT SUMMARY LP Pensacola, LLC (CON #10246), a wholly owned subsidiary of Signature Holdings II, LLC (referred to as Signature or the applicant throughout this document), proposes to establish a new 86-bed community nursing home in Leon County. Signature currently operates 25 facilities (in 18 nursing home subdistricts) with 3,146 beds in Florida: Chautauqua Rehabilitation and Nursing Center Signature HealthCARE at The Courtyard Signature HealthCARE of North Florida Washington Rehabilitation and Nursing Center The Bridge at Bay St. Joe Surrey Place Care Center Signature HealthCARE of Gainesville Signature HealthCARE of Orange Park Signature HealthCARE of Jacksonville Signature HealthCARE of Ormond Southern Pines Healthcare Center Peninsula Care and Rehabilitation Center Signature HealthCARE of Pinellas Park Golfview Healthcare Center Gulfport Rehabilitation Center Heritage Park Care and Rehabilitation Center Kenilworth Care and Rehabilitation Center Anchor Care and Rehabilitation Center Winter Park Care and Rehabilitation Center Signature HealthCARE of Port Charlotte Signature HealthCARE at College Park 2

3 Signature HealthCARE of Palm Beach Golfcrest Healthcare Center Signature HealthCARE Center of Waterford Signature HealthCARE of Brookwood Gardens The project involves 64,876 gross square feet (GSF) of new construction. The construction cost is $9,731,400. Total project cost is $16,043,610. Project cost includes land, building, equipment, project development, financing and start-up costs. The reviewer notes that the proposed facility will include a 64-bed assisted living facility (ALF) that will utilize many of the same amenities as the skilled nursing facility (SNF). The costs associated with the total facility are a project cost of $27,362,237 and construction cost of $16,676,400, involving 111,176 GSF of new construction. The applicant does not wish to accept any conditions for the proposed project. Presbyterian Retirement Communities, Inc. (CON#10247) proposes to add 72 community nursing home beds at Westminster Oaks through the conversion of 72 sheltered nursing home beds in Leon County. Westminster Oaks is a 120-bed SNF with 48 community nursing home beds and 72 sheltered nursing home beds. It is located on the campus of a continuing care retirement community (CCRC) that provides housing and services to over 750 residents. The reviewer notes that the applicant was granted an exemption beginning on April 1, 2010 that allowed the facility to open 22 sheltered beds up to the public for a five-year period, ending on March 31, The applicant operates five SNFs in Florida: Westminster Communities of Bradenton Westminster Manor Westminster Oaks of Tallahassee Westminster Towers Westminster Towers and Shores of Bradenton Winter Park Towers The proposed project is a conversion of existing licensed beds and will involve no construction or renovation. The applicant states that the only project costs are those costs associated with the CON process, a total of $25,225. The applicant proposes to condition the project as shown below: The proposed beds will be located at Westminster Oaks, 4449 Meandering Way, Tallahassee, Florida

4 PruittHealth Leon County, LLC (CON #10248), an affiliate of PruittHealth, proposes to establish a new 105-bed community nursing home or a partial request to establish an 86-bed nursing home in Leon County. PruittHealth states that the 105-bed need was achieved by aggregating 19 beds from Subdistrict 2-5 and adding this aggregation to the 86 bed published need in Subdistrict 2-4. The applicant operates one SNF with 120 beds in Florida, located in Subdistrict 1-1: PruittHealth Santa Rosa The project involves 74,383 GSF of new construction for the full award. The construction cost is $10,506,882. Total project cost is $17,189,868. Project cost includes land, building, equipment, project development, financing and start-up costs. The partial project involves 63,310 GSF of new construction. The construction cost is $8,880,494. Total project cost is $14,983,483. Project cost includes land, building, equipment, project development, financing and start-up costs. The applicant proposes to condition the project as shown below: Seek Joint Commission accreditation or accreditation from some other similarly recognized accrediting body Implement a program designed to reduce hospital readmissions Incorporate a minimum of 61.9 percent private rooms/beds into the facility design Participate in an organization-wide Quality Assurance/Performance Improvement initiative that entails quarterly visits in regard to clinical, operational, pharmaceutical and reimbursement areas by corporate consultants to ensure compliance with all local, state and federal laws Implement the WanderGuard system as a management component of the Alzheimer program Implement Electronic Medical Records (EMR) at the facility and include Smart Charting or other similar bedside patient charting tool Implement Resident Safety Technology including Call Guard and WanderGuard into the facility Implement Clinical Kiosks in appropriate locations throughout the facility Implement Alzheimer, dementia and other special behavioral health management programs 4

5 Implement the top five special amenities requested by existing health care providers in this subdistrict: o State of the art rehab suites, specialized therapy equipment, specialized care staff, therapy pool and occupational therapy kitchen Implement the top special operational initiatives requested by existing health care providers: o High percentage of private rooms, programs designed to reduce hospital readmissions, joint commission accreditation and competitive private pay room charge Implement the top five clinical services requested by existing health care providers: o Wound care, mental/behavioral health program, diabetes care, respiratory therapy and PT/OT/ST (physical therapy, occupational therapy and speech therapy) Assure all staff maintains ongoing training and continuing education credits utilizing Pruitt University and at no cost to employees Participate in a company-wide Annual Quality Report to demonstrate transparency in operations and make this Quality Report available to the public Adopt the PruittHealth patient model of care including the UniPath Programs appropriate for this facility and described in the CON application and Supporting Documents Implement PointRight Technology (or a future similar technology) in ongoing operation Maintain a minimum Medicaid percentage which exceeds the subdistrict wide average Medicaid percentage in regard to percentage occupancy Offer semi-private room rate charges not to exceed five percent greater and offer private room rate charges not to exceed 10 percent greater than the Medicaid reimbursement rate for a period of three years NOTE: Section (4) Florida Statutes, prohibits accreditation by any private organization as a requirement for the issuance or maintenance of a certificate of need, so Joint Commission accreditation (the first condition listed) will not be cited as a conditions to approval. Should the project be approved, the applicant s proposed conditions would be reported in the annual condition compliance report as required by Rule 59C (3) Florida Administrative Code. 5

6 Total GSF and Project Costs of Co-Batched Applicants Costs $ Cost Per Applicant CON # Project GSF Bed LP Pensacola, LLC New 86-bed facility 64,876 $16,043,610 $186,554 Presbyterian Retirement Communities, Inc Convert 72 sheltered beds in an existing 120-bed facility 0 $0 $0 PruittHealth Leon County, LLC New 105-bed facility 74,383 $17,189,868 $163,713 PruittHealth Leon County, LLC 10248P New 86-bed facility 63,310 $14,983,483 $174,227 Source: CON application and their respective Schedule 1 and 9 D. REVIEW PROCEDURE The evaluation process is structured by the certificate of need review criteria found in Section , Florida Statutes; and applicable rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by evaluating the responses and data provided in the application, and independent information gathered by the reviewer. Applications are analyzed to identify strengths and weaknesses in each proposal. If more than one application is submitted for the same type of project in the same district, applications are comparatively reviewed to determine which applicant(s) best meets the review criteria. Rule 59C-1.010(3)(b), Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the Certification of the Applicant. As part of the fact-finding, the consultant, Marisol Fitch analyzed the application with consultation from the financial analyst, Everett Broussard, Bureau of Central Services, who evaluated the financial data and Said Baniahmad of the Office of Plans and Construction, who reviewed the application for conformance with the architectural criteria. 6

7 E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA The following indicate the level of conformity of the proposed project with the criteria and application content requirements found in Florida Statutes, sections and ; applicable rules of the State of Florida, Chapter 59C-1 and 59C-2, Florida Administrative Code. 1. Fixed Need Pool a. Does the project proposed respond to need as published by a fixed need pool? Or does the project proposed seek beds or services in excess of the fixed need pool? Rule 59C (2), Florida Administrative Code. In Volume 40, Number 193 of the Florida Administrative Register dated October 3, 2014, a fixed need pool of 86 beds was published for Subdistrict 2-4 for the July 2017 Planning Horizon. Subdistrict 2-4 is comprised of Leon County. After publication of this fixed need pool, one existing subdistrict facility filed an exemption request or filed expedited CON reviews to add community nursing home beds. 1 As of November 19, 2014, Subdistrict 2-4 had 744 licensed and 12 approved community nursing home beds. During the 12-month period ending June 30, 2014, Subdistrict 2-4 experienced percent utilization at six existing facilities. Below is a table illustrating nursing home patient days and occupancy within Subdistrict 2-4. Leon County Nursing Home Patient Days and Occupancy July 1, 2013-June 30, 2014 Comm. Nursing Facility Home Bed Inventory Bed Days Patient Days Total Occupancy Medicaid Occupancy Centre Point Health and Rehab Center ,800 41, % 43.84% Consulate Health Care of Tallahassee ,800 41, % 50.44% Heritage Healthcare of Tallahassee ,700 62, % 73.53% Miracle Hill Nursing and Rehabilitation Center, ,800 41, % 76.66% Inc. Seven Hills Health and Rehabilitation Center ,940 50, % 66.18% Westminster Oaks 48 17,520 15, % 26.16% Total , , % 61.60% Source: Florida Nursing Home Bed Need Projections by District and Subdistrict, October 2014 Batching Cycle 1 E to add 12 community nursing home beds to Centre Point Health and Rehab Center was approved by the Agency on October 22, 2014, but not included in the fixed need publication on October 3,

8 The reviewer notes the current and projected population of Subdistrict 2-4 for the planning horizon. The projected population growth, both numerically and by percent are illustrated below. Current and Projected Population Growth Rate Leon County, District 2, and Florida January 2014 and January 2017 January 1, 2014 Population January 1, 2017 Population County Total Total Leon 250,394 30, , ,426 35, ,871 District 2 631, , , , , ,114 Florida 15,881,702 3,548,756 19,430,458 16,349,888 3,891,621 20,241, Increase Growth Rate County Total Total Leon ,590 8, % 14.88% 3.07% District 2 9,834 11,878 21, % 11.54% 2.96% Florida 468, , , % 9.66% 4.17% Source: Florida Agency for Health Care Administration Population Estimates, September 2013 The community nursing home beds per 1,000 residents for the age 65+ cohort in the subdistrict are shown below. Beds per 1,000 Residents Age 65 and Older County Community Beds 2014 Pop. Aged Beds per 1, Pop. Aged Beds per 1,000 Leon , , District 2 3, , , Florida 80,050 3,548, ,891, Source: Florida Agency for Health Care Administration Population Estimates, September 2013 and Florida Nursing Home Bed Need Projections by District and Subdistrict, October 2014 Batching Cycle Each co-batched applicant states its proposed project is being submitted in response to the Agency s fixed need pool publication dated October 3, LP Pensacola, LLC (CON #10246) states that in developing this application, it made contact with community leaders and health services providers in Subdistrict 2-4 to understand current conditions and needs. Signature states that there is currently no secure 24-hour dedicated SNF memory care unit in the county. The applicant asserts that discussions with discharge planners at Leon County hospitals, communications with the local chapter of the Alzheimer s Association and statistical data clearly show the need for additional memory care services/beds. The applicant notes that it received a letter from Mark Robinson, CEO of Capital Regional Medical Center, and spoke to Ms. Grams, Case Manager at Tallahassee Memorial Healthcare, which support Signature s focus on a secure memory unit. Ms. Farris, Associate Director of Programs and Development at the Alzheimer s Association of Central and North Florida, 8

9 also submitted a letter of support stating, The number of seniors being diagnosed with dementia and Alzheimer s is growing at a staggering rate, both locally and nationally. As Associate Direct of the Tallahassee office of the Alzheimer s Association, I am witness to the lack of available resources for this growing segment of our community, especially when it comes to placing loved ones in memory care. Signature maintains that data from the Department of Elder Affairs shows that Leon County has 3,805 probable Alzheimer cases for those 60+ years of age. Signature states that the proposed facility will have a 26-bed Wellness Memory Care Unit that will focus on admitting patients with low to moderate onset of Alzheimer s/dementia with the goal to maintain and improve cognitive function through therapeutic interventions including successful poly-pharmacy management. The applicant indicates that the unit will have private rooms with its own services so that patients can have circular travel throughout the unit and courtyard. The reviewer notes that the applicant did not condition the approval of the application to the 26-bed Wellness Memory Care Unit. The applicant maintains that the other 60 beds will comprise a shortterm rehabilitation center of excellence with a goal to return patients to their prior level of functioning while preventing readmissions to the hospital. The unit will implement the TransitionalCARE Model which incorporates the key components show to improve care coordination and improve a patient s experience. The applicant notes that the nine Signature centers where the program was piloted had an average 7.4 percent reduction in 30-day hospital readmission rates. Signature asserts that in the last four years Leon County acute care hospitals have seen a 30 percent increase in the percentage of patients discharged to SNFs. See the table below. Leon County Acute Care Patients Discharged to Skilled Nursing Facilities Excluding Newborns CY and First Quarter of st Quarter of 2014 Discharged to SNF Tallahassee Memorial Hospital 2,011 2,156 2,348 2, Capital Regional Medical Center 1,155 1,289 1,262 1, Total 3,166 3,445 3,610 3,831 1,047 Total Discharges Tallahassee Memorial Hospital 24,489 24,819 25,697 25,946 6,397 Capital Regional Medical Center 12,112 12,799 11,702 11,589 2,955 Total 36,601 37,618 37,399 37,535 9,352 % Discharged to SNF Tallahassee Memorial Hospital 8% 9% 9% 10% 11% Capital Regional Medical Center 10% 10% 11% 11% 11% Total 8.7% 9.2% 9.7% 10.2% 11.2% Source: CON application #10246, page 10 9

10 Signature states that because of the size of the proposed facility, 86 beds, it is not financially feasible for the facility to participate in the Medicaid program. Presbyterian Retirement Communities, Inc. (CON#10247) states that the proposed project will convert 72 existing sheltered nursing home beds at Westminster Oaks, a 120-bed nursing home (with 48 community and 72 sheltered beds) located in a CCRC in Tallahassee, Florida, to 72 community nursing home beds. PruittHealth Leon County, LLC (CON #10248) states its application is being submitted in response to the Agency s fixed need pool publication on October 3, The applicant states that the proposed 105-bed facility aggregated from Subdistrict 2-4 and 2-5 will serve residents of Leon, Madison, Taylor and Jefferson Counties. PruittHealth states that it completed an extensive market research initiative that included surveying/interviewing existing health care providers, analyzing existing health care provider data and conducting extensive bed need analysis. The applicant asserts that it incorporated a multitude of elements identified by the market research into the overall proposed facility plan. PruittHealth indicates that some of the most critical areas with demonstrated need the proposed facility will respond to are: The service area s health care providers indicated that the community s strongest needs in relation to beds and program mix were providing a high proportion of Medicaid services, possessing a high percentage of private rooms, offering a secure Alzheimer s unit and specialized Alzheimer s programming The service area s health care providers indicated that the community s strongest needs in relation to special operational initiatives were a facility that could provide a high percentage of private rooms, implement a program designed to reduce hospital readmissions, incorporate a high ratio of licensed nursing hours per patient day, obtain Joint Commission accreditation and offer a low private pay room charge The service area s health care providers indicated that the community s strongest need in relation to clinical services were for a facility that could provide wound care, mental/behavioral health, diabetes care, respiratory therapy and PT/OT/ST 10

11 The service area s health care providers indicated that the community s strongest need in relation to special amenities include providing state of the art rehab suites, providing specialized therapy equipment/care staff, possessing a therapy pool and an occupational therapy kitchen Pruitt Health indicates that PruittHealth Pharmacy Services and PruittHealth Medical Supply operation centers are located in Valdosta, Georgia 71 miles from Tallahassee (the major metropolitan center of Leon County). PruittHealth notes that based on data from the Alzheimer s Association and Department of Elder Affairs, there are an estimated 3,415 persons in Leon County at varying stages of Alzheimer s disease ages 65 and older. The applicant maintains that this corroborates the need for Alzheimer s specialty programming and a secure Alzheimer s unit from a new SNF in the market. PruittHealth asserts that it will incorporate an extremely comprehensive and well-established behavioral health program geared to residents with dementia. The applicant also provided data for Subdistrict 2-5 as well. See the table below. Alzheimer Estimates Population 65+ Subdistrict 2-4 and 2-5 Estimates Percent of Total Leon County 3, % Jefferson County % Madison County % Taylor County % Total 4, % Subdistrict 2-4 Total 3, % Subdistrict 2-5 Total 1, % Source: CON application #10248, page 50 The applicant notes that if the full 105-bed proposed project is approved, PruittHealth will commit to providing a secure 19-bed Alzheimer s unit, the partial award will not incorporate the secure 19-bed unit. 11

12 PruittHealth notes that both the full award and the partial award will adopt the following programmatic elements in the delivery of a comprehensive Alzheimer s and dementia care program: Care planning Resident rights and safety Dietary programs Activities program WanderGuard utilization PruittHealth states that it will incorporate each of the community s strongest needs listed above into the proposed facility. The applicant asserts that approval of the proposed facility will: Improve access for persons with Alzheimer s disease Improve access of Medicaid services Improve access to private rooms Provide a modern design that supports independence and choice Provide state-of-the-art rehabilitation programming Provide extensive clinical programming focused on reducing hospital readmissions b. If no Agency policy exists, the applicant will be responsible for demonstrating need through a needs assessment methodology, which must include, at a minimum, consideration of the following topics, except where they are inconsistent with the applicable statutory or rule criteria: Each co-batched applicant is responding to the Agency s published fixed need pool, so this criterion is not applicable. 2. Agency Rule Preferences Please indicate how each applicable preference for the type of service proposed is met. Chapter 59C-1.036, Florida Administrative Code. Chapter 59C of the Florida Administrative Code does not contain preferences relative to community nursing home beds nor does the Agency publish specific preferences for these facilities. However, the rule does contain standards the Agency utilizes in assessing an applicant s ability to provide quality care to the residents. 12

13 a. Geographically Underserved Areas. In a competitive certificate of need review within the nursing home subdistrict as defined in 59C-2.200, Florida Administrative Code, the Agency shall award a certificate of need if the applicant meets all applicable criteria for a geographically underserved area as specified in subsection (18), Florida Statutes, and if the applicant meets the applicable statutory certificate of need review criteria specified in section , Florida Statutes, including bed need according to the relevant bed need formula contained in this rule. If the applicant is awarded a certificate of need based on the provisions of this paragraph, the applicant shall agree that the nursing facility will be located in a county without a nursing facility, or in the center of an area within the subdistrict of a radius of at least 20 miles which meets the definition of a geographically underserved area. The center of the geographically underserved area shall be the proposed nursing home location in the application. None of the applications were submitted to remedy a geographically underserved area as defined above. b. Proposed Services. Applicants proposing the establishment of Medicare-certified nursing facility beds to be licensed under Chapter 400, Florida Statutes, shall provide a detailed description of the services to be provided, staffing pattern, patient characteristics, expected average length of stay, ancillary services, patient assessment tools, admission policies and discharge policies. LP Pensacola, LLC (CON #10246) states that the proposed facility will be Medicare certified and will provide rehabilitation services and skilled nursing services for short-term and long-term patients. Signature indicates that the facility will not participate in the Medicaid program. The applicant notes that the proposed project includes a separate 26-bed dedicated memory care unit. Signature declares that it will implement an individual care plan, incorporating best practices and evidence-based clinical practice guidelines for each patient. The applicant states that the proposed facility will provide an array of services, including: Physical, occupational and speech therapy Pain management Wound care 13

14 Hospice/palliative care Alzheimer s/dementia care Medical management Pulmonary, neurological and orthopedic rehab Care coordination services Transportation services Spirituality services Quality of life services Advance practice clinician services (credentialed as either nurse practitioner or physician assistant) Signature states it will provide a 15 passenger van for transportation to and from physician visits as well as transporting patients participating in the applicant s quality of life events. The applicant indicates a shift in long-term care from the nursing home to the patient s home, and has created SNF-based rehabilitation programs to enable patients to return home at a higher functional level. Signature notes that for patients requiring a longer stay in the SNF, the proposed facility will have a physical and humane environment to support and enhance quality of life and dignity. Signature states that it has developed the TransitionalCARE model to improve care coordination for all patients. This model incorporates key components shown to improve care coordination and improve a patient s experience, with an outcome of reduced hospital and nursing home readmissions. The applicant contends that in order to impact outcomes during a 90-day episode, patient engagement is essential and a component of the TransitionalCARE model. The applicant includes a full overview of the program in Tab 40 of CON application # The applicant also notes that Signature HomeNow is a subsidiary that provides home health services throughout the State of Florida with 11 branch offices in seven Florida districts. Signature states that all its home health agencies are accredited by Community Health Accreditation Program (CHAP). 14

15 Signature indicates that it has the capability to implement the following programs in the proposed facility as the community needs them: Accelerate rehabilitation units Alzheimer s/dementia Program The Signature HealthCARE Pulmonary (BreathLIFE) Program Non-medical home care The applicant notes that it was founded on three cultural pillars-- learning, spirituality and intra-preneurship with a mission to revolutionize long-term care. Signature states that it invests heavily in each pillar with dedicated staff and other resources focused on the pillars as foundational aspects of the organization. Signature states that it intends to establish contractual arrangements, including transfer agreements, with all relevant health care providers in the community. The applicant indicates that therapy services at the proposed facility will be contracted with Signature Rehab, medical supplies through Medline and pharmacy is provided through contracts with EZ-MAR and PharMerica. The applicant indicates that patients will be assessed (including all bodily systems) upon admission into the facility. Discharge planning will include assessing for safe discharge placement, durable medical equipment, education, self-care and supervision needs. Signature included copies of its admissions, transfer and discharge policies in Tab 19 of CON application # Signature maintains that it has experience in addressing the needs of the non-english speaking community and much of its printed literature is available in Spanish. The applicant provides the following table illustrating the projected admissions, patient days, average length of stay (ALOS) and average daily census (ADC) for the first two years of operation for the proposed 86-bed facility. Projected Admissions, Patient Days, ALOS and ADC Year One (ending 2/28/2018) Year Two (ending 2/28/2019) Admissions Patient Days 8,089 24,679 Medicare ALOS ADC Source: CON application #10246, page 42 15

16 Schedule 6A illustrates that FTEs for year one (ending February 28, 2018) total 35.9 and total 81.0 for year two (ending February 28, 2019). The proposed project s year one and year two FTEs are shown in the table below. The reviewer notes that the total FTEs for year one actually add up to 36.1 for year one and 80.9 for year two. LP Pensacola, LLC (CON application #10246) Projected Year One and Year Two Staffing 86-Bed Facility Year One FTEs Year Two FTEs Administration Administrator Director of Nursing Asst. DON/Transitional Care 0.8 Admissions Director Behavioral Health Specialist Medical Records Clerk MDS Coordinators Staff Coordinators Human Resources Coordinator Marketing Director Receptionist Business Ofc Mgr Nursing RNs LPNs Nurses Aides Nursing Admin, Central Supply Dietary Dietary Supervisor Dietician Cooks Dietary Aides Social Services Social Service Director Activity Director Activities Assistant Chaplain Housekeeping Housekeeping Supervision 1.0 Housekeepers Laundry Laundry Aides Plant Maintenance Maintenance Supervisor Maintenance Assistance 0.9 Total Source: CON application #10246, Schedule 6 16

17 Presbyterian Retirement Communities, Inc. (CON#10247) states that the conversion of sheltered beds to community beds does not respond to preferences as stated in the Agency rules. The applicant contends that its proposed project is to allow greater access to the community SNF so that more individuals can receive quality services. The applicant states that it will be putting into place a Rapid Rehab Program that will provide care to individuals with a variety of medical issues. Presbyterian Retirement Communities, Inc. indicates that the goal of the Rapid Rehab Program is to have residents back to their homes or assisted living in the shortest period of time reducing medical costs to all parties. Schedule 7 indicates an ALOS of for year one and for year two for the total 120-bed facility. The reviewer notes that the applicant did not provide a Schedule 7 representing solely the 72-bed conversion. The reviewer notes that the provided Schedule 7 s illustrate 7,282 incremental patient days and no incremental admissions for year one and 6,902 incremental patient days and no incremental admissions for year two of the proposed project. Schedule 6A shows that no new FTEs will be added for year one and that a total of three FTEs will be added for year two. The proposed project s year two FTEs are shown in the table below. The reviewer notes that the applicant indicates that year two will end on March 31, 2015 but does not denote when year one will end. Presbyterian Retirement Communities, Inc. (CON application #10247) Projected Year Two (Ending 3/31/2015) Staffing Year Two FTEs Nursing LPNs 2.0 Ancillary Occupational Therapist 1.0 Total 3.0 Source: CON application #10247, Schedule 6A PruittHealth Leon County, LLC (CON #10248) indicates it has designed a facility that is responsive to surveys from existing health care providers. The survey methodologies utilized by the applicant--including a copy of the survey, survey responses and how PruittHealth will respond to these needs--can be found on pages 42 through 85 of CON application #

18 PruittHealth s design and outlook for the proposed facility includes the following: 19-bed secure Alzheimer s unit in the 105-bed facility Specialized Alzheimer s programming in either size facility High percentage of private rooms (61.9 percent) private rooms--65 rooms in the 105-bed facility (full award) and 54 rooms in the proposed 86-bed facility (partial award) Enhancing Medicaid access at nine points greater than the subdistrict s current experience Hospital readmission reduction program High ratio of skilled nursing hours per patient day Joint Commission accreditation Low private pay room charge Specialized care staff Specialized therapy equipment State of the art rehab suites Therapy pool Occupational therapy kitchen Wound care Mental/Behavioral health program Diabetes care Respiratory therapy PT/OT/ST The applicant notes that essential services will include, but not be limited to the following: 24-hour nursing services Physical, occupational and speech therapy IV therapy Tube feeding and total parental nutrition Wound care management Pain management Central lines Oxygen therapy Outpatient therapy The applicant indicates that unique services and characteristics that set it apart from other nursing home providers include, but are not limited to: UniPath specialty care programs Clinic oversight teams Mandatory daily interdisciplinary team meetings 18

19 Electronic Medical Records Medication Monitoring Dedicated quality staff General and clinical kiosks PruittHealth asserts that technology to meet the needs of its patients is critical in recovery, strengthening and avoiding rehospitalization. The applicant states that the following equipment is planned for the proposed facility based on the community needs and skilled discharges from area hospitals: Nautilus leg press Nautilus triceps press Nautilus compound row Nautilus low back Nautilus 4-way neck Nautilus leg extension Biodex balance system Biodex gait trainer Biodex un-weighing system Biodex biostep Accelerated care plus modalities Ultrasound Shortwave diathermy Electrical stimulation PruittHealth discusses the programs and routine services to be offered at the proposed facility on pages 103 through 121 of CON application # The applicant states that the proposed facility will have strict admissions policies to accurately screen inquiries to assure the appropriateness of facility placement and to assure medical necessity of services. The applicant insists that based on information gathered during preadmission screening, the Admissions Committee, in consultation with the facility s Medical Director, will determine if the facility is the appropriate setting for the prospective resident. PruittHealth indicates that the proposed facility will develop a discharge plan for each resident from the day of admission for a smooth transfer of the resident from the facility to home or another care setting to provide continuity of care. PruittHealth s Schedule 7 indicates that the ALOS will be 54 days for year one and 76 days for year two of operation for the full award. Schedule 7 indicates that the ALOS will be 50 days for year one and 65 days for year two of operation for the partial award. 19

20 Schedule 6 illustrates that FTEs for year one (ending June 30, 2018) total and total for year two (ending June 30, 2019) for the full award. The proposed project s year one and year two FTEs are shown in the table below. The reviewer notes that the total FTEs for year one actually add up to for year one. PruittHealth Leon County, LLC (CON application #10248) Projected Year One and Year Two Staffing 105-Bed Facility Year One FTEs Year Two FTEs Administration Administrator Director of Nursing Admissions Director Secretary Medical Records Clerk (CNA) Other: Financial Counselor Physicians Medical Director (Contracted) Other: Physician Services (Contracted) Nursing RNs LPNs Nurses Aides RN MDS Nurse Ancillary Physical Therapist (Contracted) Physical Therapist Assistant (Contracted) Speech Therapist (Contracted) Occupational Therapist (Contracted) Occupational Therapy Assistant (Contracted) Dietary Dietary Supervisor Cooks Dietary Aides Social Services Social Service Director Activity Director Housekeeping Housekeepers Laundry Laundry Aides Plant Maintenance Maintenance Supervisor Total Source: CON application #10248, Schedule 6 Schedule 6 illustrates that FTEs for year one total and total for year two for the partial award. The proposed project s year one and year two FTEs are shown in the table below. The reviewer notes that the total FTEs for year one actually add up to for year one. 20

21 PruittHealth Leon County, LLC (CON application #10248) Projected Year One and Year Two Staffing 86-Bed Facility Year One FTEs Year Two FTEs Administration Administrator Director of Nursing Admissions Director Secretary Medical Records Clerk (CNA) Other: Financial Counselor Physicians Medical Director (Contracted) Other: Physician Services (Contracted) Nursing RNs LPNs Nurses Aides Nursing Admin, Central Supply Ancillary Physical Therapist (Contracted) Physical Therapist Assistant (Contracted) Speech Therapist (Contracted) Occupational Therapist (Contracted) Occupation Therapy Assistant (Contracted) Dietary Dietary Supervisor Cooks Dietary Aides Social Services Social Service Director Activity Director Housekeeping Housekeepers Laundry Laundry Aides Plant Maintenance Maintenance Supervisor Total Source: CON application #10248, Schedule 6 c. Quality of Care. In assessing the applicant s ability to provide quality of care pursuant to s (1) (c), Florida Statutes, the agency shall evaluate the following facts and circumstances: 1. Whether the applicant has had a Chapter 400, Florida Statutes, nursing facility license denied, revoked or suspended within the 36 months prior to the current application. 21

22 LP Pensacola, LLC (CON #10246) states that no nursing facility licenses have been denied, revoked or suspended. Presbyterian Retirement Communities, Inc. (CON#10247) did not respond to this criterion. The reviewer notes that the facility has not had its nursing facility license denied, revoked or suspended within the past 36 months. PruittHealth Leon County, LLC (CON #10248) states that none of its ultimate parent company s (United Health Services, Inc. or UHS) licensed nursing facilities have ever had its license denied, revoked or suspended. 2. Whether the applicant has had a nursing facility placed into receivership at any time during the period of ownership, management or leasing of a nursing facility in the 36 months prior to the current application? LP Pensacola, LLC (CON #10246) states that no nursing facility licenses have been place into receivership. Presbyterian Retirement Communities, Inc. (CON#10247) did not respond to this criterion. The reviewer notes that the facility has not been placed into receivership in the past 36 months. PruittHealth Leon County, LLC (CON #10248) states that none of its ultimate parent company s (UHS) licensed nursing facilities have been placed into receivership at any time, particularly in the past 36 months. 3. The extent to which the conditions identified within subparagraphs 1 and 2 threatened or resulted in direct significant harm to the health, safety or welfare of the nursing facility residents. LP Pensacola, LLC (CON #10246) states that this is not applicable as nothing was identified above. Presbyterian Retirement Communities, Inc. (CON#10247) did not respond to this criterion. The reviewer notes that this is not applicable as nothing was identified above. PruittHealth Leon County, LLC (CON #10248) states that this is not applicable as nothing was identified above. 22

23 4. The extent to which the conditions identified within subparagraph 3 were corrected within the time frames allowed by the appropriate state agency in each respective state and in a manner satisfactory to the Agency. LP Pensacola, LLC (CON #10246) states that this is not applicable as nothing was identified above. Presbyterian Retirement Communities, Inc. (CON#10247) did not respond to this criterion. The reviewer notes that this is not applicable as nothing was identified above. PruittHealth Leon County, LLC (CON #10248) states that this is not applicable as nothing was identified above. 5. Rule 59C (4) (f) Harmful Conditions. The Agency shall question the ability of the applicant to provide quality of care within any nursing facility when the conditions identified in the subparagraph (e) 1 and (e) 2 result in the direct, significant harm to the health, safety or welfare of a nursing facility resident, and were not corrected within the time frames allowed by the appropriate state agency in each respective state and in a manner satisfactory with the Agency. LP Pensacola, LLC (CON #10246) states that this is not applicable as nothing was identified above. Presbyterian Retirement Communities, Inc. (CON#10247) did not respond to this criterion. The reviewer notes that this is not applicable as nothing was identified above. PruittHealth Leon County, LLC (CON #10248) states that this is not applicable as nothing was identified above. 23

24 d. Rule 59C (5) Utilization Reports. Within 45 days after the end of each calendar quarter, facilities with nursing facility beds licensed under Chapter 400, Florida Statutes shall report to the Agency, or its designee, the total number of patient days, which occurred in each month of the quarter, and the number of such days that were Medicaid patient days. LP Pensacola, LLC (CON #10246) states that it will provide the required data to the applicable local health council and to the Agency. Presbyterian Retirement Communities, Inc. (CON#10247) did not respond to this criterion. The reviewer notes that the applicant currently provides the required data to the applicable local health council and to the Agency. PruittHealth Leon County, LLC (CON #10248) states that it will provide the required data to the applicable local health council and to the Agency. 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 applicants service area? ss (1)(b) and (e), Florida Statutes. There are 32 licensed community nursing homes with a total of 3,709 community nursing home beds in District 2. Subdistrict 2-4 is composed of Leon County and has six licensed community nursing homes with a total of 744 community nursing home beds. The subdistrict averaged percent total occupancy for the 12-month period ending June 30, LP Pensacola, LLC (CON #10246) states that Leon County has the fastest growing senior population in District 2, it is expected to grow 25 percent between 2014 and 2019 a rate much faster than the state (18 percent). Signature reports that the total occupancy of the six SNFs in Nursing Home Subdistrict 2-4 exceeds that of the district and the state. See the table below. 24

25 Subdistrict 2-4 Skilled Nursing Facility Occupancy July 1, 2013 to June 30, 2014 Facility Beds Patient Days Occupancy Centre Pointe Health and Rehab Center , % Consulate Health of Tallahassee , % Heritage Healthcare Center at Tallahassee , % Miracle Hill Nursing and Rehabilitation Center, , % Inc. Seven Hills Health and Rehabilitation Center , % Westminster Oaks 48 15, % Subdistrict 2-4 Total , % District 2 Total 3,709 1,201, % Florida Total 80,050 25,521, % Source: CON application #10246, page 50 The applicant contends that given the calculated bed need, current occupancy rates of the subdistrict, discussions with discharge planners and projected aged population growth an 86-bed SNF would benefit the community and meet the growing demand in the county. Signature notes the obvious need for Alzheimer/dementia care services in Tallahassee as there is currently no secure 24-hour dedicated SNF memory care unit in the county. The applicant indicates that the proposed facility will have a multi-sensory environment (MSE) a collection of sensory activities or equipment that can be provided to people with varying types of disabilities. Signature states that is has a model of specialized care to individuals suffering from Alzheimer s and other forms of dementia, Serenity HealthCARE. The applicant maintains that Serenity HealthCARE utilizes the following core innovative approaches to lead to better clinical outcomes: Education Comprehensive assessments Psych Rx management The Bridge The applicant states that it has added services beyond its nursing homes with specialized operating units to provide care coordination services in the community to improve continuity of care. Signature contends that this makes it a highly valued provider with unique capabilities that are welcomed additions to an acute care system s network. Signature maintains that implementation of these programs will have a positive impact on patient experience and clinical outcomes for patients in the subdistrict. The applicant states that the following specialized operating units and capabilities will be available at the proposed facility: Nurse practitioner service Palliative care program 25

26 The Signature HealthCARE Wound Program Home health skilled services The applicant included a DVD of videos about Signature facilities, culture, values and amenities. Signature asserts that the phrase quality of life is all-encompassing and integrates not only clinical care, but spiritual, mental and emotional. The applicant maintains that it takes the time and effort to shirk the restraints of traditional nursing home activities programming in favor of something much more diverse, vibrant and tailored to the specific desires of its residents. Signature states that this is the fourth consecutive year where patients have been taken on an annual vacation. The applicant indicates that its robust quality of life programming exists to keep patients active while delivering dynamic activities tailored to their individual wants and needs. The applicant provides the following table illustrating the projected admissions, patient days, ALOS and ADC for the first two years of operation for the proposed 86-bed facility. Projected Admissions, Patient Days, ALOS and ADC Year One (ending 2/28/2018) Year Two (ending 2/28/2019) Admissions Patient Days 8,089 24,679 Medicare ALOS ADC Source: CON application #10246, page 42 Presbyterian Retirement Communities, Inc. (CON#10247) states that Tallahassee has a number of high quality health care facilities in the area. The applicant affirms that it has access to these providers. Presbyterian Retirement Communities asserts that its reputation in the Tallahassee area has required other providers in the service area to obtain the applicant s standards to remain competitive. The applicant notes that it has working relationships with Tallahassee Community College and Florida State University medical programs, professors and students. Presbyterian Retirement Communities asserts that these relationships have provided higher levels of service and in a number of cases shorter stays for a resident. The reviewer notes that the applicant did not provide any data to support these statements. Presbyterian Retirement Communities states that it is a not-for-profit organization that has operated CCRCs and HUD Low Income Elderly Apartments for over 50 years. 26

27 The applicant notes that its extension to allow 21 sheltered beds to be utilized as community beds will end March 31, 2015 and the applicant contends that after that time it will no longer be able to provide skilled nursing care for 21 community residents that require skilled nursing care. 2 The reviewer notes pursuant to Chapter (7), Florida Statues the Agency is allowed to grant CCRCs an extension of the fiveyear period for sheltered nursing beds to be used by persons who are not residents of the CCRC. Nothing precludes the applicant from applying for another extension as long as it meets the criteria for granting such an extension. The reviewer notes that the applicant did not provide any utilization for the existing sheltered beds or how many of these beds are utilized by continuing care contract residents. The applicant makes no indication of provisions to ensure access to nursing home beds for residents of the CCRC in its application. It is unclear how approval of the proposed conversion, which includes all 72 of the applicant s sheltered beds, would improve availability and accessibility to skilled nursing care for residents of the CCRC. The reviewer created the following charts from the applicant s Schedule 7. The reviewer notes that in these schedules, the applicant states that year one will end March 31, 2016 and year two will end March 31, Presbyterian Retirement Communities, Inc. Forecasted Utilization Total 120-Bed Facility Year One Year Two Total Admissions Total Patient Days 42,508 42,128 Occupancy 97.05% 96.2% Source: CON application #10247, Schedule 7 Presbyterian Retirement Communities, Inc. Forecasted Utilization Proposed Conversion Incremental Increase Year One Year Two Incremental Admissions 0 0 Incremental Patient Days 6,902 7,282 Incremental Occupancy 16.63% 16.6% Source: CON application #10247, Schedule 7 PruittHealth Leon County, LLC (CON #10248) reports the proposed services area is home to 12 nursing homes with an aggregated 1,259 licensed beds. Leon County (for the partial award) is home to six nursing homes with 744 licensed beds. The applicant notes that of the four 2 The reviewer notes that the applicant s extension has 22 approved beds, not