STATE AGENCY ACTION REPORT ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number Brooks Skilled Nursing Facility A, Inc./CON #10133 3599 University Boulevard South Jacksonville, Florida 32216 Authorized Representative: Brian Fuller Vice President of New Business Development & Planning (904) 345-7736 2. Service District/Subdistrict District 4, Subdistrict 4-3 (St. Johns and Southeast Duval Counties). B. PUBLIC HEARING A public hearing was not held or requested on the proposed project to construct a 119-community nursing home. Letters of Support There are six letters of support included in CON application #10133. These letters were dated between October 19, 2011 and December 6, 2011. The letters are described below. James B. Wood, President and CEO of Memorial Hospital Jacksonville, writes that Brooks Rehabilitation Hospital and Memorial Hospital share a common history as well as close proximity. Mr. Wood notes that the proposed facility, Provides an opportunity for a seamless transition of the patients we discharge from our hospital. Since we discharge nearly 2,000 patients to skilled nursing facilities each year, it is a benefit to be able to refer them to a facility we are certain will provide the highest level of care.
Linda Levin, Executive Director of ElderSource the Area Agency on Aging and Aging Disability Resource Center for Northeast Florida, states, With Brooks reputation as a leading provider of rehabilitation services, I am confident that their new facility will provide innovative, high-quality care in a state-of-the-art environment designed to get patients back home. Ms. Levin also participated in a focus group with Brooks and adds, I was impressed with their willingness to solicit feedback from those in the community who help place seniors in skilled nursing or assisted living facilities every day. Dr. Goar de Lamerens, Medical Director of Brooks San Marco Terrace Rehab and Care, indicates that he witnesses firsthand the quality of care that Brooks provides to patients at San Marco Terrace. Dr. de Lamerens adds, Patients are always looking for a skilled nursing facility that provides quality care through its expert staff and environment. The proposed facility will offer that and more with a great number of private rooms, handicapped accessible bathrooms and large common areas for socialization. Two letters were from members of the Brooks Rehabilitation Medical Group. Brooks Rehabilitation Hospital Medical Director of Admissions, Dr. Kerry Maher, writes, Brooks has the staff expertise and the resources to develop another patient-centric rehabilitation model within the skilled nursing facility setting, creating a great solution for patients that want to return home. Dr. Trevor H. Paris, Brooks Rehabilitation Hospital Medical Director, notes, The zip code in which the proposed site lies has a larger elderly population which is growing at a more rapid pace compared to the existing location and thus will be better able to accommodate future demand. Patricia debear, Senior Vice-President and Hospital Administrator of Brooks Rehabilitation Hospital, states, The location would also allow residents access to Brooks extensive body of knowledge in a wide variety of rehabilitation specialty services and post-acute settings; ongoing education and research through Brooks partners including University of North Florida, University of Florida and Duke University; and multiple levels of care and community programs that will maximize the potential for the best outcomes. 2
C. PROJECT SUMMARY Brooks Skilled Nursing Facility A, Inc. (CON #10133) proposes to construct a 119-bed replacement skilled nursing facility in District 4, Subdistrict 4-3, Duval County. The applicant has an inactive license which was issued effective August 11, 2011. The proposed project will be located approximately 3.4 miles from its former location near the intersection of Beach and University Boulevards, adjacent to Memorial Hospital Jacksonville and Brooks Rehabilitation Hospital within zip code 32216. The total cost of the project is $21,047,486. The project involves 93,986 total gross square feet (GSF) of new construction with a construction cost of $14,469,666. Costs covered are for land, building, equipment, project development, financing and start-up costs. The applicant proposes the following conditions: The proposed facility will be constructed on a parcel of land currently owned by Brooks Health System, reflected in the site plan submitted with the proposal on Hickman Road proximate to Beach and University Boulevards. To provide a minimum of 20 percent of total patient days to Medicaid recipients. D. REVIEW PROCEDURE The evaluation process is structured by the certificate of need review criteria found in Section 408.035, Florida Statutes; and applicable rules of the State of Florida, Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project successfully is conducted by assessing the responses 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 best meet the review criteria. 3
Section 59C-1.010(3) (b), Florida Administrative Code, allows no application amendment information subsequent to the application being deemed complete. The burden of proof to entitlement of a certificate rests with the applicant. As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the Certification of the Applicant. As part of the fact-finding, the consultant, Marisol Novak, analyzed the application in its entirety with consultation from the Financial Analyst, Felton Bradley, 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. 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 Sections 408.035 and 408.037, Florida Statutes; 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-1.008(2), Florida Administrative Code. Pursuant to Section 408.0435 (1) Florida Statutes, the Florida Legislature extended a moratorium on the issuance of any certificate of need (CON) for increases in the number of community nursing home beds around the state until Medicaid managed care is implemented statewide pursuant to Sections 409.961-409.985 Florida Statutes, or October 1, 2016, whichever is earlier. Due to the moratorium, a fixed need pool was not published by the Agency. This project, if approved, will not change the bed count in the planning area. The applicant seeks approval to construct a 119-bed community nursing home in District 4, Subdistrict 4-3. See the map below. 4
Brooks Skilled Nursing Facility A, Inc. (CON #10133) and Skilled Nursing Facilities Within a Two Point Five-Mile Radius Source: MapPoint 2006 @ Microsoft 5
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: Population demographics and dynamics. Availability, utilization and quality of like services in the district, subdistrict, or both. Medical treatment trends. Market conditions. Population Demographics and Dynamics: The applicant states that demographic data shows a large elderly population with expected projected growth for the area that will be served by the proposed facility. Utilization data shows the subdistrict nursing homes occupancy is greater than 90 percent and higher than the statewide 87.5 percent utilization for the most recent 12-month period. The reviewer confirmed that subdistrict 4-3 had an occupancy rate of 90.13 percent and the state 87.51 percent for the 12-month period ended June 30, 2011. 1 Brooks maintains that the restoration of the 119 beds, that are currently inactive, would ease any overcrowding and allow for population growth. Brooks indicates that the proposed project provides the subdistrict with a new physical plant and improved location still within a four-mile radius of the former owner s location. The applicant gathered data to show the disparity in the size and age of the facilities within the subdistrict to compare to the proposed project. Brooks maintains that this information illustrates that the proposed project will enhance residents quality of life through the provision of increased space for living, dining, therapies and the pursuit of activities that can be accommodated within the new building. See the table below. 1 Florida Nursing Home Utilization by District and Subdistrict July 2010-June 2011, published September 30, 2011. 6
Age and Heated/Cooled Square Footage Nursing Homes in Subdistrict 4-3 Facility Name Licensed Beds Age of Plant Heated/Cooled Sq. Ft. Total Heated/Cooled Sq. Ft./bed Fannie Taylor Home for the Aged, Inc. 24 40 40,301 1,679 Life Care St. Johns, Inc. 30 10 46,348 1,545 Fleet Landing 80 21 107,031 1,338 CON #10133 119 NEW 93,986 790 Regents Park of Jacksonville 120 25 89,072 742 River Garden Hebrew Home for the Aged 180 22 128,000 711 Vicar s Landing Nursing Home 60 23 39,849 664 Westminster Woods on Julington Creek 60 37 38,935 649 Life Care Center of Jacksonville 120 7 76,083 634 Samantha R Willson Senior Citizens 120 13 75,594 630 Atrium Healthcare Center 84 15 43,140 514 Cypress Village 120 20 61,264 511 Southpoint Terrace 120 8 57,223 477 Avante Villa at Jacksonville Beach Inc. 165 38 65,499 397 Consulate Health Care of Jacksonville 116 15 44,599 384 Palm Garden of Jacksonville 120 21 44,935 374 San Jose Health and Rehabilitation Center 120 26 42,471 354 Moultrie Creek Nursing and Rehab Center 120 25 41,170 343 Heartland Health Care Center, S. Jax 117 31 39,558 338 The Ponce Therapy Care Center 120 27 40,363 336 Southlake Nursing & Rehabilitation Center 180 29 57,870 322 St. Augustine Health & Rehabilitation Center 120 34 36,234 302 Riverwood Center 240 48 62,495 260 First Coast Health and Rehabilitation Center 100 48 25,620 256 San Marco Terrace Rehabilitation & Care 68 46 16,633 245 Former Glenwood Nursing Center 119 46 23,873 201 Taylor Care Center 120 Unknown Unknown Unknown Subdistrict 4-3 Average (without CON #10133) 27 53,766 568 Source: CON application #10133, page 1-7. Note: Duval County facility age and square footage figures above only include buildings where coded as Building Type 7302-Nursing Home. St. Johns County facility age and square footage figures above only include buildings where coded as Building Type/Description 5400/Nurs Home. The applicant s bed counts include community and sheltered nursing home beds. The applicant s subdistrict 4-3 average square feet per bed without CON #10133 is the average of the 25 facilities square footage, which is higher than the subdistrict s actual square footage per bed. As shown above, the applicant s chart shows a total of 2,823 beds (not including CON #1013 and Taylor Care Center which does not have square footage) and 1,344,160 total square feet which results in an average of 476 square feet per bed. Therefore, the applicant s projected 790 square per bed exceeds the subdistrict average by 314 square feet (790-476 SF). The applicant notes that it examined the elderly population and population growth by age cohort, since skilled nursing care is predominately provided to elders. Brooks examined the zip code for the proposed facility as well as the zip code for the current site. 7
Brooks states that the data shows that the age 65-year and older population within the zip code (32216) of the proposed site grew by 17.9 percent compared to 3.3 percent for the existing facility s 32211 zip code in the most recent five-year period ending in 2011. Furthermore, the five-year growth rate of the proposed site s zip code was more than five times that of the growth rate of the existing facility s zip code. The proposed site zip code also has a larger total population of 65 years and older population compared to the existing location. The applicant maintains that these demographic factors bode well for the success of the proposed project as more seniors and total population move into the proposed site zip code. See the table below. Population and Growth by Elderly Age Cohort 2006-2011 2006 Population Current Site Zip Code (32211) Proposed Site Zip Code (32216) Subdistrict 4-3 Florida Age 65+ 3,608 4,139 70,561 3,070,269 Age 75+ 1,736 1,947 31,731 1,512,414 Age 85+ 394 488 7,984 405,949 Total Population 32,135 32,822 628,693 17,938,643 2011 Population Zip Code 32211 Zip Code 32216 Subdistrict 4-3 Florida Age 65+ 3,728 4,880 84,631 3,347,608 Age 75+ 1,899 2,455 38,192 1,667,694 Age 85+ 578 778 11,948 531,038 Total Population 33,160 35,465 694,476 18,991,634 2006-2011 Growth Zip Code 32211 Zip Code 32216 Subdistrict 4-3 Florida Age 65+ 3.3% 17.9% 19.9% 9.0% Age 75+ 9.4% 26.1% 20.4% 10.3% Age 85+ 46.7% 59.4% 49.6% 30.8% Total Population 3.2% 8.1% 10.5% 5.9% Source: CON application #10133, page 1-9. Brooks contends that the tremendous growth in elderly individuals shown above, can create challenges with respect to the provision of health care services thereby making the most efficient use of skilled nursing beds under the moratorium a priority. Therefore, the applicant asserts the importance of moving the 119 currently inactive beds to active status by constructing a replacement facility to serve this community which recently lost access to care within these beds. The applicant notes that subdistrict 4-3 is projected to experience continued growth, especially for those individuals 65+. Over the next five years, subdistrict 4-3 s age 65+ population is projected to increase by 25.9 percent compared to the State of Florida at 15.9 percent. See the table below. 8
Projected Population and Growth by Elderly Age Cohort 2011-2016 2016 Population Current Site Zip Code (32211) Proposed Site Zip Code (32216) Subdistrict 4-3 Florida Age 65+ 4,029 5,379 106,540 3,881,236 Age 75+ 1,783 2,482 42,768 1,818,440 Age 85+ 625 851 13,711 600,898 Total Population 33,452 36,362 754,187 20,234,338 2011-2016 Growth Zip Code 32211 Zip Code 32216 Subdistrict 4-3 Florida Age 65+ 8.1% 10.2% 25.9% 15.9% Age 75+ -6.1% 1.1% 12.0% 9.0% Age 85+ 8.1% 9.4% 14.8% 13.2% Total Population 0.9% 2.5% 8.6% 6.5% 2011-2016 Compounded Annual Growth Zip Code 32211 Zip Code 32216 Subdistrict 4-3 Florida Age 65+ 1.6% 2.0% 4.7% 3.0% Age 75+ -1.3% 0.2% 2.3% 1.7% Age 85+ 1.6% 1.8% 2.8% 2.5% Total Population 0.2% 0.5% 1.7% 1.3% Source: CON application #10133, page 1-10. Brooks maintains that the project will remain in an area where the growth rate for the elderly exceeds that of the total population and the site of the relocation will have more elderly and higher elderly growth rates than the existing zip code. The applicant asserts that the strong population growth rates for the elderly age cohorts indicate a sustained demand for nursing home beds over the next five years. Availability, utilization and quality of like services in the district, subdistrict or both. Brooks cites that subdistrict 4-3 has 26 skilled nursing facilities and 2,770 community nursing home beds. For the 12-month period ending June 30, 2011, the utilization for the subdistrict was 90.13 percent including Glenwood Nursing Center s operational 119 beds. The applicant notes that going forward, higher occupancies will persist until the 119 beds from Glenwood are returned to active status. Brooks asserts that the high occupancy rate for the proposed service area demonstrates need for the project. The applicant proposes to construct, equip and staff a high quality nursing home to serve subdistrict 4-3. The facility will be designed with the needs of the community in mind, focusing on short-term rehabilitative skilled nursing care. The proposed facility will contain: 9
71 private rooms A large state-of-the-art therapy suite Higher staffing levels specific to the needs of rehabilitative care Generously sized resident rooms All resident rooms and bathrooms will be handicap accessible An abundance of common areas and outdoor space to foster independence. Brooks operates San Marco Terrace and the skilled nursing unit at St. Luke s Hospital. Both facilities have received a five-star overall rating in their most recent CMS rating and both were listed by U.S. News and World Report as a Top 10 nursing home in Florida in 2011. The applicant states that an interdisciplinary team will provide an array of services in accord with each resident s care plan. These services will include but are not limited to: Physical, occupational and speech therapies Outpatient rehabilitation Cardiac and stroke rehabilitation Neurological rehab Pain management Restorative nursing program Wound care program IV therapy Customized pressure support systems Infectious disease treatment Psychological services Registered dietician services Individual meal planning Brooks indicates that other services and amenities include: structured activities seven days a week, pet therapy, daily transportation, beauty/barber shop, off-site social activities and more. The applicant maintains that its practice is to develop a preliminary plan of care to meet the resident s immediate needs within the first 24 hours of admission with a care plan developed within five days of the completion of a comprehensive assessment. Each care plan contains measurable objectives and timetables to meet the resident s medical, nursing, mental and psychological needs. Brooks states that many of 10
the processes and quality initiatives in place at its other facilities will be utilized at the proposed replacement facility. The applicant concludes that these will assure quality care, which will be further enhanced by the improved physical environment of the new facility. Medical Treatment Trends Brooks maintains that Florida has been focused on shifting care away from nursing homes in response to rising health care costs. The applicant cites that Medicaid patient days in proportion to total patient days have slowly, but steadily, decreased since the nursing home bed moratorium was initiated, indicating fewer long-term patients. Brooks indicates that the declining rates of Medicaid utilization in proportion to the elderly population is expected to continue for Duval County as nursing home diversion projects continue to expand and alternative treatment options and resources are sought for long-term care. Brooks contends that while there have been many alternatives for nursing homes for individuals requiring long-term care, patients requiring rehabilitation services in nursing homes (requiring shorter stays) has grown. The applicant states that skilled nursing facilities are moving toward a short-stay rehabilitation focus. Skilled nursing facilities still provide both short and long-term care and utilization continues to increase, but with an increasing trend in short-term rehabilitative care and declining trend in the provision of long-term skilled care. The applicant states that in recent years the Centers for Medicare and Medicaid Services has placed restrictions on the type of patients (i.e. major joint replacement and other conditions) that can be admitted at inpatient rehabilitation facilities. Brooks concludes that these limits on major joint replacement patients and other conditions requiring rehabilitation are likely to result in an increase in nursing home admissions as many of these patients no longer qualify to be admitted in inpatient rehabilitation facilities. Market Conditions Brooks states that the population growth, in particular the elderly population in the proposed service area has led to a greater need for health care services. The applicant cites Memorial Hospital Jacksonville, located directly across the street from the proposed site, increasing its capacity by 21 percent over the last five years by adding a 72-bed patient tower in 2010. Brooks notes that as the hospital has grown so has the need for rehabilitation and skilled nursing for those recovering from illness or surgical procedures. 11
The applicant states that there has been a growth of 65+ discharges at Memorial Hospital Jacksonville in recent years. From 2006 to 2010, Memorial Hospital Jacksonville s 65+ discharges have increased from 7,256 to 8,092 a growth of 11.52 percent. Brooks indicates that the trend experienced in the nursing home industry is a demand for rehabilitation and to return home, with the great need for rehabilitation following an acute care hospital stay. Data shows that the zip code for the proposed facility had 434 acute care discharges to skilled nursing facilities, with the majority (58.8 percent) coming from Memorial Hospital Jacksonville. The applicant asserts that this illustrates that a large number of residents within a very close proximity to the proposed site have required rehabilitation following an acute care episode. See the table below. Hospital Discharges to Skilled Nursing Facilities For Patients Age 65 & Over Living in Zip Code 32216 Calendar Year 2010 Facility/Hospital Discharges Percent Memorial Hospital Jacksonville 255 58.8% St. Luke s Hospital 71 16.4% Saint Vincent s Medical Center 27 6.2% Baptist Medical Center 26 6.0% Mayo Clinic 19 4.4% Shands Jacksonville Medical Center 14 3.2% Baptist Medical Center Beaches 10 2.3% Baptist Medical Center South 7 1.6% Orange Park Medical Center 3 0.7% Flagler Hospital 1 0.2% Ocala Regional Medical Center 1 0.2% Total 434 100.0% Source: CON application 10133, page 1-19. The applicant identified the number of acute care discharges to skilled nursing facilities for residents age 65+ living within the proposed zip code by Major Diagnostic Category (MDC) for 2010. Brooks maintains that this data shows that the highest group of discharges disease and disorders of the musculoskeletal system and connective tissue, diseases and disorders of the circulatory system and diseases and disorders of the respiratory system all commonly require rehabilitation. See the table below. 12
Calendar Year 2010 Hospital Discharges to Skilled Nursing Facilities by Major Diagnostic Category For Patients Age 65 & Over Living in Zip Code 32216 MDC Code MDC Description Discharges Percentage 08 Musculoskeletal System & Connective Tissue 81 18.7% 05 Circulatory System 70 16.1% 04 Respiratory System 69 15.9% 11 Kidney & Urinary Tract 67 15.4% 06 Digestive System 30 6.9% 01 Nervous System 27 6.2% 18 Infectious & Parasitic Diseases 23 5.3% 09 Skin, Subcutaneous Tissue & Breast 14 3.2% 10 Metabolic Diseases/Disorders 12 2.8% 07 Heptabiliary System and Pancreas 9 2.1% 16 Blood/Blood Forming Organs/Immunity Disorder 7 1.6% 23 Factors Influencing Health Status 6 1.4% 21 Injury, Poisoning & Toxic Effects 6 1.4% 19 Mental Diseases/Disorders 5 1.2% PR Pre MDC 2 0.5% 24 Multiple Significant Trauma 2 0.5% 00 Unknown 2 0.5% 20 Substance Use 1 0.2% 12 Male Reproductive System 1 0.2% Total 434 100.0% Source: CON application #10133, page 1-20. The applicant asserts that given the current diseases and conditions treated within the target zip code and the numbers of discharges to skilled nursing care, post-acute options represented by this project to restore the 119 beds into service is the highest and best use of the applicant s resources. Brooks indicates that in addition to acute-care discharges, comprehensive medical rehabilitation hospitals also discharge patients to skilled nursing facilities. Brooks Rehabilitation Hospital, located directly across the street from the proposed facility, discharged 329 patients to skilled nursing facilities in 2010 165 of whom resided within subdistrict 4-3. The applicant contends that the proximity will afford patients discharge options as they leave the rehabilitation hospital that will allow them to remain close by, enhancing the availability of skilled nursing care. Furthermore, the applicant maintains that Brooks and Brooks Rehabilitation Hospital will have processes and information technology systems in place to make the transition from CMR to skilled nursing as seamless as possible, thus improving efficiency and quality. 13
Brooks also indicates that 30 percent of patients discharged from a skilled nursing facility require home health services and six percent require outpatient rehabilitation. 2 Brooks Health System, the applicant indicates, is one of the largest home health agencies in northeast Florida with a network of more than 25 outpatient rehabilitation clinics. Brooks contends that by coordinating patients care throughout their episode of illness, Brooks Health System has the capability to improve quality, reduce rehospitalizations and reduce the costs of delivering care to these patients. The applicant states that the data presented shows that a skilled nursing facility benefits local residents without adverse impact to other providers as no new beds will be added to the subdistrict. Brooks indicates that the net effect of the proposed project is to retain licensed capacity rather than reduce in the light of forecasted increases in demand. The applicant concludes that the proposed facility benefits residents of the subdistrict and district as the continuation of the nursing home bed moratorium allows no new capacity. 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-1.036 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. 2 According to a report published by RTI International in 2009, Examining Post-Acute Care Relationships in an Integrated Hospital System. 14
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 408.032(18), Florida Statutes, and if the applicant meets the applicable statutory certificate of need review criteria specified in section 408.035, 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. The applicant states that this application is not submitted to remedy a geographically underserved area as defined by rule. The proposed project involves the construction of a new skilled nursing facility to replace 119 currently inactive beds. Brooks indicates that this provision is not applicable to the replacement sought in this proposal. 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. Brooks states that the proposed facility will be constructed with three stories containing 71 private rooms and 24 semi-private rooms configured in a neighborhood design consistent with the Agency s focus on resident-driven care. The physical plant design will permit the proposed facility to have the space and equipment needed for additional rehabilitation services, including a large therapy gym with separate areas for physical, speech and occupational therapy. Brooks indicates that the gym will be specially designed with separate treatment areas to accommodate 15
residents with neurological problems who cannot tolerate excessive stimulation. The proposed facility will also include a healing garden and other exterior areas that will be used for therapy as well. Brooks states that an interdisciplinary team will provide an array of services in accord with each resident s care plan. Patient services will include but are not limited to: Physical, occupational and speech therapies Outpatient rehabilitation Cardiac and stroke rehabilitation Neurological rehabilitation Pain management Restorative nursing program Wound care program IV therapy Customized pressure support systems Infectious disease treatment Psychological services Registered dietician services Individual meal planning Other services and amenities that will provide support, comfort and security include: Structured activities seven days a week Pet therapy One hundred percent electric beds Security system Multi-lingual staff Daily transportation Television and telephone Wireless internet access Off-site social activities Snack bar bistros Beauty/barber shop Whirlpool spa 16
Brooks states that a preliminary plan of care will be developed to meet the resident s immediate need within the first 24 hours and a care plan will be developed within seven days of completion of a comprehensive assessment. The applicant indicates that each care plan contains measurable objectives and timetables to meet the resident s medical, nursing, mental and psychological needs. The care planning interdisciplinary team includes but is not limited to: Attending physician Director of nursing Charge nurse responsible for resident care Registered nurse assigned to the resident Nursing assistants responsible for the resident s care Dietary manager Social service manager Activities director Therapists, as appropriate Consultants, as appropriate Others as appropriate or necessary to meet the needs of the resident The applicant maintains that the care plans incorporate goals and objectives that lead to the resident s highest possible level of independence. Brooks states that when a resident s discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident and family adjust to the new living environment. As the applicant is affiliated with Brooks Health System, processes are in place to manage the resident throughout their recovery in the system s continuum of services from assisted living to home health to outpatient therapy. In regards to admissions, the applicant states that a physician must personally approve a recommendation for admission of an individual and residents must remain under the care of a physician. At the time of admission, the nursing services department provides residents and family members with an orientation to the facility, an agreement outlining services covered and the resident s rights policy. Also, during the admissions process the charge nurse will make a preliminary assessment and record general information. 17
Brooks indicates that prior to or upon admission, the social services director or designee provides written information to the resident concerning his/her right to make decisions concerning medical care. The facility will provide notice and operate in accordance with OBRA guidelines and state law. The applicant states that a physician s order will be obtained for all discharges. A post-discharge plan will be developed by the care plan team and provided to the resident and his/her family. Social services will review the plan with the resident and his/her family to ensure that all services necessary for follow-up care are provided. A discharge summary will be filed in the patient record. The applicant provides a list of its affiliated Brooks Health System outpatient rehabilitation centers that it states promote continuing access to retain health status gains made while in the skilled nursing facility (page 2-5 of CON application #10133). Additionally, Brooks Health System operates one of the largest home health agencies in District 4 which will provide continued skilled nursing and therapy services to discharged skilled nursing patients in a home setting. The following table contains the proposed staffing pattern for the facility. 18
Brooks Skilled Nursing Facility A, Inc. Staffing Patterns for Year One and Year Two of Operations Year One FTEs Ending 6/30/2015 Year Two FTEs Ending 6/30/2016 Administration Administrator 1.0 1.0 Director of Nursing 1.0 1.0 Admissions Director 1.0 1.0 Medical Records Clerk 1.0 1.0 Business Office Manager 1.0 1.0 Business Service Representative 1.0 1.0 MDS Coordinator 1.0 2.0 TOTAL 7.0 8.0 Nursing RN 6.2 9.7 LPN 10.5 16.4 Nurses Aide 43.2 67.7 TOTAL 59.9 93.8 Ancillary Physical Therapist 6.2 9.7 Speech Therapist 1.0 2.3 Occupational Therapist 4.4 6.8 TOTAL 11.5 18.8 Dietary Dietary Supervisor 1.0 1.0 Servers, cooks, etc. 6.2 9.7 TOTAL 7.2 33.6 Social Services Social Services Director 1.0 1.0 Activities Director 1.0 1.0 Activities Assistant 1.3 2.1 Social Services Staff 1.0 1.9 TOTAL 4.3 6.0 Housekeeping Housekeeping Supervisor 1.0 1.0 Housekeepers 4.9 7.7 TOTAL 5.9 8.7 Laundry Laundry Aides 4.3 6.7 TOTAL 4.3 6.7 Plant Maintenance Maintenance Supervisor 1.0 1.0 TOTAL 1.0 1.0 GRAND TOTAL 101.1 153.7 Source: CON application #10133, schedule 6. Brooks states that the staffing patterns and the number of fulltime equivalents are based on historical experience. The applicant states that it contracts with a medical director through a contractor service agreement. 19
Chapter 400.23, Florida Statutes requires a minimum licensed nursing staffing of 1.0 hours of direct care for each resident per day and a minimum certified nursing assistant staffing of 2.5 hours of direct care for each resident per day. Additionally, s. 400.23 (3)(a)1. a., Florida Statutes, states that there must be a minimum weekly average of certified nursing assistant and licensed nurse staffing of 3.6 combined hours of direct care per resident per day. The calculations below are based on the applicant s proposed staffing from Schedule 6 and projected occupancy from Schedule 5 of the application. Brooks Skilled Nursing Facility A, Inc. Minimum Staffing Requirements FTE Nurses/Aides Minimum Requirement 1 st Year (end June 30, 2015) 2 nd Year (end June 30, 2016) Nurses 1.0 hours of direct care per resident 1.36 1.36 Aides 2.5 hours of direct care per resident 3.53 3.52 Sources: CON application #10133, schedules 5 and 6. As illustrated in the above table, the applicant s projected staffing patterns meet the minimum requirements outlined in Section 400.23 (3)(a)1, Florida Statutes. In addition, nursing staff must include at least one professional nurse per 40 residents and one nurse s aide per 20 residents. The applicant s projections are in compliance with these requirements. The proposed new facility will accept a variety of payers including Medicare, Medicaid, self-pay and other payers. Admissions are projected at 592 in year one and 927 in year two. Average length of stay remains constant both years at 43 days, while the average daily census increases from 71 in year one to 111 in year two. These statistics are illustrated in the table below. 20
Brooks Nursing Facility A, Inc. Projected Admissions, Patient Days, Average Length of Stay and ADC First Two Years of Operation Year One Year Two Admissions 592 927 Patient Days 25,644 40,221 ALOS 43 43 ADC 71 111 Source: CON application #10133, schedules 5, 6 and 7. c. Quality of Care. In assessing the applicant s ability to provide quality of care pursuant to s. 408.035(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. The applicant has not had a nursing facility 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? Brooks has not had a nursing home placed into receivership at any time. 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. This provision does not apply. 21
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. This provision does not apply. (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 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. This provision does not apply. (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. Brooks states that it will continue to provide the required data to the Health Planning Council of Northeast Florida and to the Agency for Health Care Administration. This includes the above-cited utilization reports as well as required licensure and financial requirements attendant to operating a licensed nursing facility. 3. Statutory Review Criteria a. Is need for the project evidenced by the availability, quality of care, accessibility and extent of utilization of existing health care facilities and health services in the applicant s service area? ss. 408.035(1)(a) and (b), Florida Statutes Subdistrict 4-3 includes St. Johns County and southeast Duval County and has 23 licensed community nursing homes with 2,770 beds. Included in the total are Glenwood Nursing Center s 119 beds that are 22
currently inactive and the subject of the proposed replacement facility in this application. The applicant states that no new beds will be added to the subdistrict, rather inactive beds will be reopened in an area with higher demand. Brooks maintains that an important feature of CON application #10133 is the emphasis on resident-directed care and amenities that support both long and short stays in the skilled nursing facility. The applicant contends that the proposed facility makes a marked improvement on the availability of the skilled nursing beds as a health care resource. The applicant reiterates the information it presented in its Need Analysis, stating that as the 119 beds from Glenwood Nursing Center remain inactive, higher occupancies will persist until the proposed facility represented in CON application #10133 return the 119 beds to use. Brooks states that due to the moratorium, no additional community nursing homes will be added in the state, thereby increasing demand for skilled nursing services. The applicant contends that the restoration of the 119 skilled beds assures availability and access to skilled care. Brooks proposes to construct, equip and staff a high quality nursing home to serve subdistrict 4-3, which has and will experience growth. The proposed facility will be designed with the needs of the community in mind, focusing on short-term rehabilitative skilled nursing care and a return to the resident s home. The applicant maintains that by tailoring care to patients with similar needs, a higher level of service and staffing ratio can be implemented efficiently to establish a viable program with excellent results for those it serves. The proposed project will include features to improve resident care, including: A large number of private rooms All rooms will have handicap accessible bathrooms with showers The facility design consists of resident neighborhoods to foster culture change Multiple dining rooms, living rooms and outdoor spaces A healing garden Beauty/barber salon Multiple refreshment stations where beverages and snack items are served throughout the day A large therapy gym with separate areas for physical, speech and occupational therapy. 23
The applicant indicates that resident care in the proposed facility will be directed by multidisciplinary teams based upon plans of care for residents where objectives for each are set and progress noted. Brooks also notes that all nursing staff including certified nursing assistants, therapy aides and others with direct resident care responsibilities will maintain skill levels. The applicant will provide continuing education courses and tuition reimbursement will be available. Additionally, staff will be promoted from within to assure continuity of care. The applicant states that the other two skilled nursing facilities it operates, San Marco Terrace and the skilled nursing unit at St. Luke s Hospital, have received a five-star overall rating in their most recent CMS rating and both were listed by U.S. News and World Report as a Top Ten nursing home in Florida in 2011. Brooks asserts that based on its ability to provide excellent care in its existing locations, quality will be assured at the proposed facility. Brooks states that the proposed facility will be located near the intersection of Beach and University Boulevards within zip code 32216. Beach and University Boulevards are both major thoroughfares within the subdistrict with high traffic counts. Beach Boulevard provides access to the proposed facility for residents living east and west of the location, while University Boulevard provides a corridor for those living north and south. No obstacles such as railways, bridges or other potential barriers that could impede traffic exist near the proposed location. The applicant maintains that due to the proposed location being at the intersection of two major roads within the subdistrict and a short drive from Interstate 95, access for all residents of the subdistrict will be assured. Furthermore, the applicant indicates that the proposed location will be in an area with the highest concentration of the elderly population within the subdistrict. Brooks states that of the 106,540 persons aged 65 years and older projected to be living within the subdistrict, 49,327 (46.30 percent) live within a 20-minute drive of the proposed facility. The proposed facility will be directly across from Memorial Hospital Jacksonville and Brooks Rehabilitation Hospital, and will serve patients needing skilled nursing care after hospitalization. The applicant asserts that the proposed geographic location is expected to improve access to those most likely to need skilled nursing care. 24
The applicant states it will continue to be a provider in the Medicare and Medicaid Programs as well as accepting a variety of insurance plans. These plans include HMOs, PPOs and traditional indemnity programs (employer sponsored health care options). Brooks assures that declining an admission based on payer will not occur in the proposed facility. Therefore, financial access is assured. b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? ss. 408.035(1)(c), Florida Statutes The applicant states that Brooks Skilled Nursing Facility A, Inc. was created in June 2010, to acquire and operate San Marco Terrace Rehabilitation and Care. Brooks maintains that it is accomplishing an integrated network to address the broad needs of the elderly, who use disproportionally more of the nation s health care dollar. The proposed project is designed to address short-term and long-term care needs with emphasis on services of greater complexity such as wound care, joint replacement therapies and tube-feeding. Brooks states that it holds an overall five-star rating at the San Marco facility in the Medicare Nursing Home Compare 3 one of only seven (out of 23) in the subdistrict to receive this rating. San Marco Terrace received five out of five stars on health inspections and quality measures and four out of five stars on nursing home staffing. Brooks notes that San Marco Terrace participates in the American Health Care Association/National Center for Assisted Living s (AHCA/NCAL) National Quality Award Program. San Marco Terrace has received the Bronze Award and is working to achieve the Silver Award. 4 3 This was confirmed by the reviewer. Survey results can be found at http://www.medicare.gov/nhcompare/include/datasection/resultssummary/onehome_allresults.asp?dest=nav Home Search OneHomeAllResults HomePage~ProximitySearch~HomeSelect&OneHomeN HC=105645%7CSAN+MARCO+TERRACE+REHABILITATION+AND+CARE&SortField=#TabTop. 4 Per the association s website at http://www.ahcancal.org/quality_improvement/quality_award/pages/default.aspx, the AHCA/NCAL National Quality Award Program provides a pathway for providers of long-term care services to journey towards performance excellence. The Quality Award program has three progressive step levels (Bronze, Silver and Gold). Applications are judged by trained Examiners who provide feedback on opportunities for improvement to support continuous learning. Facilities must achieve an award at each level to progress to the next level. 25
The applicant indicates that the proposed project will benefit from Brooks experience at San Marco and its rating requirements and quality assurance protocols. Brooks states that comprehensive training protocols will be used to ready staff at the proposed facility to implement the established standards for delivering quality care. Brooks has established a quality assurance/risk management program consisting of a team of individuals internal and external to the organization. The team meets once a month to analyze trends and develop action plans. Plans are adjusted as necessary based on their effectiveness. Brooks maintains that key to making change continuous is to incorporate resident council initiatives and concerns voiced in meetings, raised by residents or raised by medical professionals that provide care and management. The applicant asserts that its approach is focused on resident-centered care, thereby defining standards from the residents viewpoint and challenging staff to invest in new techniques. Brooks maintains that the personalization of care is the cornerstone of the culture change movement. The applicant states that it works to develop measures to capture the residents objectives of what quality care should be. The applicant lists other programs developed and implemented at San Marco Terrace to promote the delivery of quality care. A full description of these programs is included in CON application #10133 on pages 4-4 through 4-5. These programs include: Guardian Angel Program Vohra Wound Care Program Standards of Care Work Group Pharmacy Consultant Dietician Intervention CAN Nurse Council Activities Brooks states that it is committed to quality staff. The applicant invests in education and provides tuition reimbursement to LPNs seeking RN degrees. 26
The applicant asserts that the proposed facility s staffing levels will exceed those required by law and that the majority of the clinical staff will have expertise in rehabilitation. The staff will possess the necessary training and equipment to run a successful skilled nursing facility. Brooks notes that the nursing programs will focus on restorative care, physical/occupational/speech therapies and other services as needed to minimize recovery time and return residents home. Brooks states that the facility s activities director will be responsible for keeping residents busy and providing residents with many opportunities to participate in various forms of recreation for improving mind and body. Residents and their families will have the following activities and special events each month, including but not limited to those listed below: Board Games Exercise Ice cream socials Movies and snacks Balloon volleyball Birthday parties Bingo Musical performances Special brunches and dinners Crafts Educational seminars Happy hour Special holiday celebrations Church services Brooks maintains that through historical quality services, an affiliation with a respected health care provider and through the design of a new facility to promote culture change quality will be assured for the proposed project. Agency records indicate that the applicant had no substantiated complaints since Brooks Skilled Nursing Facility A, Inc. took over operation of San Marco Terrace on June 29, 2010. 27