94-001010CON St. Anthony&Apos;S Hospital, Inc. vs. Nme Hospitals, Inc., And Agency For Health Care Administration Status: Closed Recommended Order on Monday, July 24, 1995.

Summary: Not normal circumstances not present in open heart surgery case that would lead to grant of a Certificate of Need.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

ST. ANTHONY'S HOSPITAL, INC. )

)

Petitioner, )

)

vs. ) CASE NO. 94-1010

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent, )

and )

)

BAYFRONT MEDICAL CENTER, INC., )

and LARGO MEDICAL CENTER, INC., )

)

Intervenors. )

________________________________)

RECOMMENDED ORDER

This case was heard from July 20 through July 22, 1994, and from July 25

through July 28, 1994 in Tallahassee, Florida, by David M. Maloney, Hearing

Officer for the Division of Administrative Hearings.

St. Anthony's Hospital, Inc., and Largo Medical Center, Inc., filed

proposed recommended orders on October 12, 1994. Two days later, October 14,

1994, St. Anthony's filed an amended proposed recommended order and Bayfront

Medical Center, Inc., and the Agency for Health Care Administration filed a

joint proposed recommended order. Rulings on the findings of fact in the

amended proposed recommended order and proposed recommended orders of the

Respondent and Intervenors are contained in the appendix to this order.

APPEARANCES

For Petitioner: Robert D. Newell, Jr.

NEWELL & STAHL

817 North Gadsden Street

Tallahassee, Florida 32303

For Respondent: S. Dean Bunton

Agency for Health Care Administration

325 John Knox Road

The Atrium, Suite 301

Tallahassee, Florida 32303-4131

For Intervenor: Stephen A. Ecenia

Bayfront Thomas W. Konrad

Rutledge, Ecenia, Underwood

Purnell & Hoffman, P.A.

215 South Monroe Street, Suite 420

Tallahassee, Florida 32301-1841

For Intervenor: James C. Hauser

Largo Parker, Skelding, Labasky,

Corry, Eastman & Hauser, P.A.

Post Office Box 669

Tallahassee, Florida 32302

John D. C. Newton, II

Suzanne Mann

Messer, Vickers, Caparello,

Madsen & Goldman, P.A.

Post Office Box 1876

Tallahassee, Florida 32302-1876

STATEMENT OF THE ISSUE

Whether this case presents "not normal circumstances" that lead to award to

St. Anthony's Hospital, Inc., of a certificate of need for an Open Heart Surgery

program?

PRELIMINARY STATEMENT

On February 25, 1994, the Division of Administrative Hearings received a

Notice signed by the Agency Clerk for the Agency for Health Care Administration,

("AHCA," or the "Agency.") The notice advised that a request for a formal

administrative hearing had been received from St. Anthony's Hospital, Inc. The

notice further requested that a hearing officer be assigned to conduct all

necessary proceedings culminating in a Recommended Order.

Attached to the notice was St. Anthony's Petition for Formal Hearing. The

petition contests the preliminary denial by the Agency of St. Anthony's

application, CON application No. 7418, for a certificate of need to provide open

heart surgery at St. Anthony's Hospital in AHCA District 5.

Subsequent to the docketing of the case as No. 94-1010, the case was

consolidated with another case. The case, No. 94-1011, initiated by NME

Hospitals, Inc. d/b/a Palms of Pasadena Hospital was later voluntarily dismissed

and a closing order was entered on June 13, 1994. This case, Case No. 94-1010,

then proceeded to hearing by itself on July 20, 1994. In the meantime,

Petitions to Intervene, filed by Bayfront Medical Center, Inc., and Largo

Medical Center, Inc., were granted subject to proof of standing at hearing.

At hearing, St. Anthony's presented the testimony of 11 witnesses and

offered into evidence 19 exhibits, No.s 1-14, 16, 19-21 and 23, all of which

were admitted into evidence with the exceptions of portions of St. Anthony's

Exhibit No. 23. Official recognition was taken of St. Anthony's Exhibit No. 22.

St. Anthony's Exhibits 15, 17 and 18 either were not offered or were withdrawn.

Largo presented the testimony of 3 witnesses and offered 7 exhibits, Nos. 1-7,

all of which were admitted into evidence. Bayfront offered the testimony of 2

witnesses and 11 exhibits, Nos. 1-3 and 5-12. Bayfront Ex. No. 4 was not

offered. Of the remaining 11 exhibits all were admitted into evidence with

exception of Bayfront Ex. No. 1, which was declared inadmissible.

FINDINGS OF FACT

a. The parties and existing programs in District 5.

1. St. Anthony's Hospital, Inc., the applicant for CON No. 7418 (the

subject of this proceeding), is a not-for-profit corporation. Its facility, St.

Anthony's Hospital, at which the adult open heart surgery program would be

operated if CON No. 7418 were granted, is a 427-bed licensed general community

hospital providing adult acute medical services in surgery, psychiatry and

obstetrics. Located south of Ulmerton Road in Pinellas County, (generally

considered "South Pinellas County,") St. Anthony's also provides home health

care, family medicine clinics, outreach education, health screening and

occupational health.

2. Also located in South Pinellas County are Bayfront Medical Center, All

Children's Hospital, and Northside Hospital. Northside is not a party to this

proceeding although it recently received approval for a CON to provide open

heart surgery services. Northside is located 6-1/2 to 7 miles from St.

Anthony's and provides services in the same service area.

3. Bayfront Medical Center, Inc., is one of two intervenors in this

proceeding. Its facility, Bayfront Medical Center is a 518-bed, acute care,

not-for-profit hospital located within the limits of the city of St. Petersburg

and 1.7 miles from St. Anthony's. It offers cardiac, cancer and emergency

services as well as a Level II trauma center. Bayfront also maintains a large

women's and children's program, a rehabilitation center and a neurology program.

Its cardiology program includes adult and pediatric cardiac catheterization,

angioplasty and open heart surgery. But the open heart surgery program is

shared with All Children's Hospital. Pre-operative and post-operative patient

care is Bayfront's responsibility. The actual surgery takes place on the

premises of All Children's.

4. All Children's Hospital is a research hospital affiliated with the

University of South Florida College of Medicine. Most importantly, and

certainly most pertinent to this case, it is a dedicated Class II pediatric

specialty hospital, one of two pediatric specialty hospitals in Florida, and one

of only 47 in the nation. It provides, therefore, primary, secondary and

tertiary care for children, in addition to the open heart surgery services it

provides adults. Its cardiac surgery program was grandfathered under CON law to

begin children's cardiac surgery in 1975. At the time of the grandfathering,

All Children's was asked by state officials to consider adult cardiac surgery

services as well. The hospital trustees and medical staff agreed and began a

combined pediatric/adult open heart surgery program in 1976. As explained,

above, the adult program is shared with Bayfront. All Children's Hospital is

not a party to this proceeding.

5. Largo Medical Center, Inc.'s facility, Largo Medical Center is a 256-

bed, acute-care hospital specializing in cardiology and open heart surgery.

Largo, the other intervenor in the proceeding, is located in AHCA's District 5

but outside South Pinellas County, as are two other open heart surgery programs:

a program at Morton F. Plant Hospital in Clearwater and a program at HCA Bayonet

Point/Hudson Medical Center located in Hudson in Pasco County. Morton F. Plant

Hospital and HCA Bayonet Point/Hudson Medical Center are not participants in

this proceeding.

6. The Agency for Health Care Administration is the single state agency

authorized by Section 408.034(1), Florida Statutes, to issue or deny

certificates of need, "written statements ... evidencing community need for a

new ... health service [such as an adult inpatient cardiac catheterization

program.]" Section 408.032(2), Florida Statutes.

b. Standing of the Intervenors.

7. Over half of Largo's open heart surgery patients originate from St.

Anthony's defined service area and 35 percent from South Pinellas County. If

St. Anthony's achieves its projected volume, Largo likely will lose 35 percent

of its open heart surgery patients in the third year of operation. A loss of

that number of patients will contribute to a substantial loss of revenue to

Largo.

8. As concerns Bayfront's standing to intervene in this proceeding, St.

Anthony's purpose in seeking a CON for an open heart surgery program is to

obtain authorization for a program to take the place of the All

Children's/Bayfront adult open heart surgery program. As counsel for St.

Anthony's made clear in oral representation during hearing, whether made clear

from the face of St. Anthony's application or not, the application is a

"replacement application for Bayfront/All Children's [open heart surgery

program]." (Tr. 208.)

c. Filing of the CON application

9. Under cover of a certification of its authorized agent dated September

17, 1993, St. Anthony's Hospital, Inc., filed an application for Certificate of

Need 7418 with the Agency for Health Care Administration. The application seeks

expansion of existing cardiology services at St. Anthony's health care facility

in Pinellas County to include an on-site program for adult open heart surgery.

d . Background

10. This is not the first time St. Anthony's has initiated proceedings to

obtain a CON for open heart surgery. It has filed applications before because

of its concern that South Pinellas County is not being served appropriately by

the adult open heart services program shared by Bayfront Medical Center and All

Children's Hospital. In the application in this case, St. Anthony's describes

its previous attempts in this way:

... St. Anthony's has on eight occasions, since

1987, applied for a Certificate of Need to

provide open heart surgery services. Each

application has either been denied, or was

withdrawn by St. Anthony's based on represent-

ations St. Anthony's received that

All Children's/Bayfront shared program was

adequate and appropriate to meet the needs

of south Pinellas adult open heart patients.

St. Anthony's has historically deferred to

All Children's so as not to unnecessarily

duplicate services.

St. Anthony's Ex. 1, p 27.

11. In CON application 7396, filed July 14, 1993, All Children's Hospital

requested AHCA to allow the hospital "to discontinue services to the adult

cardiac surgery population effective June 30, 1994 ...". St. Anthony's Ex. No.

20, attachment at p.7. The reason for the request was that All Children's had

experienced and projected to continue to experience growth in its pediatric

surgery caseload. Since "All Children's mission and legal responsibility lies

with Florida's children ... the [hospital's] obvious difficulty ... [was] how to

continue dealing with a growing pediatric patient load with decreasing

availability of facilities." Id.

12. At the same time, although not increasing as rapidly as children's

surgery, the growth of the caseload for adult open heart surgery, as of the

summer of 1993, was continuing in St. Petersburg. As a licensed pediatric

hospital, All Children's opined in CON Application 7396,

[W]e are unable to expand the adult program

in even a moderate fashion and are unable to

provide the true continuum of adult cardiac

care that adult cardiologists and surgeons

believe to be needed in the community. Only

an adult licensed hospital can provide those

services and allow for future growth.

Id., at 8.

With regard to the growing pediatric patient load threatened by decreasing

availability of facilities, the application projected, "a true crisis within one

year in the surgery, SICU area if adjustments are not made to alleviate the

situation." Id.

13. The crisis, however, did not materialize. As of June 20, 1994, nearly

one year after the filing of the withdrawal application, the President and Chief

Executive Officer of All Children's Hospital was of the opinion that there was

not a crisis in the care of pediatric patients. Nor was there a crisis in the

care of adult open heart surgery patients. In fact, adult open heart surgery

patients were receiving very high quality care within one year of the projection

of crisis made in the application.

14. The application to terminate the open heart surgery program was

withdrawn prior to June 20, 1994. All Children's withdrew the application in

response to wishes expressed in the community that the program be continued.

15. Nonetheless, St. Anthony's viewed the representations made by All

Children's in CON application 7396 to "impeach any continued suggestion by All

Children's or Bayfront that the existing shared services agreement is a normal

or appropriate setting for adult open heart services." St. Anthony's Ex. No. 1,

pg. 27. It filed, therefore, the application that initiated this proceeding.

eansfer Stress and Limitations

of the All Chidren's/Bayfront OHS program.

16. After pre-operative care at Bayfront, adult open heart surgery

patients are transferred through an enclosed corridor connecting Bayfront to All

Children's. The same corridor is used to transfer the patients back to Bayfront

for appropriate post- operative care following the surgery and intensive care at

All Children's.

17. Patients typically suffer stress when being transferred from one

institution to another. They certainly suffer "transfer stress" when being

transferred from St. Anthony's to Bayfront for open heart surgery in the All

Children's/Bayfront program, just as they would suffer stress in transfers from

Bayfront to St. Anthony's were St. Anthony's application to be granted and were

the St. Anthony program to take the place of the All Children's/Bayfront

program.

18. Typical transfer time, however, between Bayfront and All Children's is

only about five minutes. Most patients do not realize they are going from one

institution to another. Although the arrangement is less than ideal, it is

doubtful that open heart surgery patients suffer stress due to the transfers

from Bayfront to All Children's and back again.

19. There are, however, some drawbacks with regard to angioplasty patients

in the All Children's adult program. Ambulation of angioplasty patients cannot

be appropriately observed postoperatively at All Children's because there are

not telemetry facilities available at All Children's for observation. There are

such facilities at Bayfront and the patients may be observed there post-

operatively once out of the intensive care unit at All Children's.

20. Carlos M. Estevez, M.D., is a cardiologist with St. Petersburg Medical

Clinic with active privileges at St. Anthony's, Bayfront, All Children's and

Edward White Hospital. Beds have been unavailable postoperatively for adult

therapeutic anigoplasty patients of his on occasion at All Children's. The

patients have been required to be transferred to Bayfront or back to St.

Anthony's, with French sheaths in their groin, a less- than-ideal situation.

21. Dr. Estevez' therapeutic anigoplasty patients requiring open heart

backup at All Children's are typically discharged from All Children's after

spending the night in the intensive care unit. For the average angioplasty

patient, intensive care services are an overutilization of services.

22. Dr. Estevez believes "crisis" would be a fair term to describe the

current situation for his angioplasty patients in the All Children's/Bayfront

program.

f. Not Normal Circumstances

23. Part of CON review is to look for factors the application shows to be

"beyond the norm," or "any unusual circumstances." AHCA's interrogatory answer

responded with regard to defining "not normal circumstances," in this way:

There is no definition for "not normal circum-

stances." In the absense (sic) of a projected

numeric need pursuant to a fixed pool publication,

an applicant may demonstrate valid need, justi-

fiable evidence of situations or occurrences in

a service area which are not accounted for such

as access problems, which may support approval.

St. Anthony's Ex. 7, p. 9.

g. Circumstances of the All Children's/Bayfront Program.

24. As a dedicated Class II pediatric specialty hospital, All Children's,

alone, cannot provide the continuum of care needed by adult open heart surgery

patients. Its provision of services, as stated above, is limited to surgery and

postoperative intensive care. Other services in the continuum of care required

by adult open heart surgery patients include admission to an emergency room, and

pre-operative coronary care as well as post-operative care (other than intensive

care) all the way through cardiac rehabilitation. The components of the

continuum other than the actual surgery and post-op intensive care are provided

by Bayfront and other hospitals. Despite All Children's inability to provide

"continuum of care," by itself, to adult open heart surgery patients, the care

provided the open heart surgery patient in the All Children's/Bayfront program

is of high quality.

25. All Children's physical site is limited for future growth both as to

the adult open heart program and its pediatric programs. The physical outer

limits of the hospital building are right on the property line, "all the way

around. It has no room to expand." St. Anthony's Ex. No. 20.

26. But for physical limitations, All Children's pediatric services would

expand because the need for expansion in the pediatric program exists. The

inability of the pediatric programs to expand compromises All Children's

mission: pediatric care in a hospital dedicated to pediatrics. The adult open

heart surgery program, if withdrawn, would free All Children's somewhat for

further pediatric program growth both as to resources and space. But All

Children's is no longer trying to withdraw from the program.

27. All Children's board of trustees believes that only an adult licensed

hospital can provide the continuum of care needed for adult open heart surgery

patients and allow for future growth. Moreover, it is not possible to put

together a competitive adult open heart pricing structure for the continuum of

care that one hospital could provide when adult open heart surgery patients are

being transferred from All Children's to and from other hospitals in order to

provide the full continuum of care.

h. AHCA's Response to the Application.

28. AHCA's response to the application was denial based on a determination

of no need to support the application. After review, AHCA determined that the

application did not demonstrate that St. Anthony's could support sufficient

volume even were the All Children's/Bayfront program to become non-operational.

There was, however, an even more fundamental objection to granting the

application on the part of the agency. As Elizabeth Dudek, Chief of the

Certificate of Need and Budget Review sections of the agency, explained with

regard to St. Anthony's premise that the application seeks to have its program

"replace" the All Children's/Bayfront adult open heart surgery program,

I don't understand that premise. I don't

understand it because, one, the All Children's/

Bayfront program is still operational. There

is no indication that the All Children's/Bayfront

program has somehow indicated that it would

relinquish its program volume to St. Anthony's.

[A]dditionally, ... by law they wouldn't be able

to [accomplish a transfer] through the CON program,

you can't transfer [or replace] a program ...

Tr. 1534, ll. 2-12.

i. Need.

29. For those in need of open heart surgery services in South Pinellas

County, there is another facility in South Pinellas County at which the services

can be obtained: Northside. As for all of AHCA District 5, there are other

facilities at which open heart surgery services are available. There is no

evidence, despite the inability of the All Children's/Bayfront adult program to

expand, that the needs of those requiring high quality open heart surgery

services in South Pinellas County or AHCA District 5 are going unmet.

CONCLUSIONS OF LAW

30. The Division of Administrative Hearings has jurisdiction over the

parties and subject matter of this proceeding. Sections 120.57(1) and

408.039(5), F.S.

31. As existing providers of adult open heart surgery services in District

5, which will serve patients who, if St. Anthony's application is granted, could

receive those services at

either their facilities or at St. Anthony's, both Bayfront Medical Center,

Inc., and Largo Medical Center, Inc., have standing to participate in this

proceeding.

32. Pursuant to Section 408.036(1), Florida Statutes, and 59C-1.004(2),

Florida Administrative Code, an application to provide adult open heart services

is subject to review by the Agency for Health Care Administration and requires

the filing of an Application for Certificate of Need.

33. The statutory and rule criteria applicable to this de novo review of

CON 7418 are found in sections 408.035, 408.037, 408.039, Florida Statutes, and

Rule 59C-1.033, Florida Administrative Code.

34. St. Anthony's Hospital, Inc., has the burden of demonstrating that it

is entitled to the certificate of need. Florida Department of Transportation v.

J.W.C. Co., 396 So. 2d 778 (Fla. 1st DCA 1981), Boca Raton Artificial Kidney

Center v. Department of Health and Rehabilitative Services, 475 So.2d 260 (Fla.

1st DCA 1985). A balanced consideration of applicable statutory and rule

criteria must be made. Humana, Inc. v. Department of Health and Rehabilitative

Services, 469 So.2d 889 (Fla. 1st DCA 1985). Such consideration requires that

varying weight be accorded each criterion depending on the facts of each case.

Collier Medical Center, Inc. v. Department of Health and Rehabilitative

Services, 462 So.2d 83 (Fla. 1st DCA 1985).

35. Among the criteria that must be considered in evaluating an

application for a CON is the need for the proposed services. AHCA has

established an open heart surgery methodology that, normally, must be satisfied

before any new OHS programs will be approved. To this end, AHCA has adopted a

numeric need methodology. See Rule 59C-1.033(7)(b), F.A.C. AHCA further

provides, however, that "[a] new adult open heart surgery program shall not

normally be approved ... if ... [t]here is an approved open heart surgery

program in the district." Rule 59C- 1.033(7)(a)1., F.A.C. The evidence in this

case demonstrates that Northside has an approved open heart surgery program in

the district. Accordingly, there is no numeric need.

36. Of course, St. Anthony's does not contend otherwise. St. Anthony's

seeks to establish entitlement to a certificate of need through the existence of

"not normal" circumstances.

37. The circumstances surrounding the All Children's/Bayfront shared adult

open heart surgery program, as established through the confirmation by All

Children's President and Chief Executive Officer of the statements contained in

All Children's CON Application No. 7396, are certainly unusual. The adult open

heart surgery program is not able to expand despite an increase in demand. But

there are other facilities both in South Pinellas County and elsewhere in

District 5 which are available to serve adult patients who may be unable to

obtain open heart surgery services from the All Children's/Bayfront program.

38. Of more import to health care, in general, is the effect the shared

program has on the pediatric programs at All Children's. It seems clear from

the evidence that All Children's mission, "pediatric care in a hospital

dedicated to pediatrics" is suffering due to the presence of the adult open

heart surgery facilities in the hospital. What to do about the impact to the

pediatric programs and the mission of All Children's Hospital, however, at least

on the state of record in this proceeding, is a matter for its Board of

Trustees. Moreover, in addition to the question of whether the adult program's

impact on the pediatric programs at All Children's is relevant to whether St.

Anthony's should be granted an adult open heart surgery CON, there is another

pressing question. What would happen to the All Children's/Bayfront shared

program, if St. Anthony's application were granted? There is no evidence that

it would simply wither away. Furthermore, as Ms. Dudek explained so succinctly,

there is no procedure to replace or transfer an existing program with another.

Nor is there evidence of any proceeding underway, or basis in law, for that

matter, to revoke or limit to pediatrics All Children's open heart surgery

program.

39. Questions surrounding the "replacement" nature of St. Anthony's

application, aside, St. Anthony's, at bottom, has failed to establish the need

for an open heart surgery program at its facility. As stated in Humosco, Inc.

et al. v. Department of Health and Rehabilitative Service, 14 FALR 244, (DOAH

December 12, 1991),

It is impossible to list all of the circum-

stances where a new program could be approved

even in the absence of "numeric need." Examples

of not normal circumstances include a showing of

inaccessibility, excessive utilization of a

particular facility, or an intentional or an

intentional action by an existing provider to

keep its utilization below [a minimum number]

of annual procedures. Other factors may include

exceptional circumstances as they relate to the

review criteria listed in Section 381.705, Florida

Statutes, evidence of an unusual payor mix,

established referral patterns among existing

providers or evidence to suggest that an existing

program could not reach ... minimum procedure

volume because of poor quality.

Id. at 262.

Dr. Estevez' testified that, on occasion, his angioplasty patients requiring

open heart backup must spend the night in All Children's ICU, an overutilization

of services. This overutilization is not enough, by itself, to establish need

for another open heart surgery program in South Pinellas County particularly

when a new program has just been established at Northside. See Rule 59C-

1.002(66), F.A.C. establishing open heart surgery as a tertiary health service

and the definition of "tertiary health service," in Section 408.032(19):

[A] health service which, due to its high level

of intensity, complexity, specialized or limited

applicability, and cost, should be limited to an

concentrated in, a limited number of hospitals

to ensure the quality, availability, and cost-

effectiveness of such service ... (e.s.)

40. Despite the establishment by St. Anthony's of the existence of unusual

circumstances surrounding the All Children's/Bayfront shared program, there is

no evidence that these circumstances creates the need for an open heart surgery

program at St. Anthony's.

41. St. Anthony's has established that it would be better for Florida's

pediatric patients if All Children's would relinquish its adult open heart

surgery program. There is no basis of record, however, that the presence of the

shared program is injurious to adult open heart surgery patients. They have

adequate facilities in South Pinellas County and in District 5 from which to

choose and to receive high quality open heart surgery services. Absent further

change in circumstances, there is no need for an adult open heart program at St.

Anthony's, however well-qualified St. Anthony's is to conduct one.

Accordingly, it is RECOMMENDED:

That Certificate of Need Application No. 7418 be DENIED.

DONE and ORDERED this 24th day of July, 1995, in Tallahassee, Leon County,

Florida.

___________________________________

DAVID M. MALONEY

Hearing Officer

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

[phone]

Filed with the Clerk of the

Division of Administrative Hearings

this 24th day of July, 1995.

APPENDIX

The following rulings are made on the parties' proposed findings of fact:

St. Anthony's Proposed Findings of Fact in its Amended PRO:

Proposed Findings of Fact Nos. 1 - 8, 85 - 90, 93, 95, 96 98-105, 107 -

109, 113 - 115, 133, and 138, insofar as material, are accepted.

Proposed Findings of Fact Nos. 9 - 84, 111, 112, 116 - 132, 134, 135, 136

are rejected as irrelevant.

Proposed Findings of Fact No. 91 and 92 are rejected because the transfer

between Bayfront and All Children's and back again, is as if the patient is in

one hospital. With regard to a third facility, transfers are no different than

any transfer from an admitting hospital to the hospital where the surgery is

conducted. See St. Anthony's Ex. No. 23, Estevez Deposition, pg. 56.

Proposed Finding of Fact No. 94 is rejected as uncorroborated hearsay.

Proposed Finding of Fact No. 97 is accepted as Dr. Estevez' opinion but it

does not establish that the All Children's/Bayfront open heart surgery program

is in a crisis.

Proposed Finding of Fact No. 106 is rejected. See rulings on Findings 91

and 92, above.

Proposed Finding of Fact No. 136 is rejected. The quality of care is

determined to be good in the All Children's/Bayfront program.

Proposed Finding of Fact No. 110 is accepted with the recognition that All

Children's by itself cannot provide the "continuum of care" necessary for adult

open heart surgery programs. The necessary continuum is provided in conjunction

with Bayfront.

Proposed Finding of Fact No. 139 first sentence is rejected as without any

foundation in the evidence. The second sentence is accepted.

Proposed Findings of Fact Nos. 106 and 107 are rejected.

Bayfront and AHCA's Proposed Findings of Fact in their Joint Pro:

Proposed Findings of Fact Nos. 1 - 17, 24 - 30, 34, 61 - 65, 67 - 77, 88,

125, 126, 127, 135 - 139, and 141 - 147, insofar as material are adopted.

Proposed Findings of Fact Nos. 18 - 23, 32, 33, 35 - 60, 66, 78 - 86, 89 -

124, and 128 - 134, are rejected as irrelevant.

Proposed Finding of Fact 31 is rejected. St. Anthony's proposed to become

the third provider of OHS primarily serving the residents of South Pinellas

County.

The first sentence of Proposed Finding of Fact No. 87 is rejected. It is

not necessary to the recommended disposition of the case to reach the issue of

whether the All Children's/Bayfront program is a more reasonable alternative to

what St. Anthony proposes. The second sentence of the finding is accepted.

With respect to Proposed Finding of Fact No. 140, expansion is not an

alternative. Implementation of proposed modifications may be an alternative to

the current program at All Children's/Bayfront.

Largo's Proposed Findings of Fact in its PRO:

Proposed Findings of Fact Nos. 1 - 14, 25 - 27, 32, - 77, 132, 133, 164,

165, 166 insofar as material are accepted.

Proposed Finding of Fact Nos. 15 - 24, 28 - 31, 78 - 131, 134 - 163 are

rejected as irrelevant.

Proposed Finding of Fact No. 167 is disregarded.

COPIES FURNISHED:

Robert D. Newell, Jr.

NEWELL & STAHL

817 North Gadsden Street

Tallahassee, FL: 32303

S. Dean Bunton

Agency for Health Care Administration

325 John Knox Road

The Atrium, Suite 301

Tallahassee, FL 32303-4131

Stephen A. Ecenia

Thomas W. Konrad

Rutledge, Ecenia, Underwood,

Purnell & Hoffman, P.A.

215 South Monroe St.

Tallahassee, FL 32301-1841

James C. Hauser

Parker, Skelding, Labasky, Corry,

Eastman & Hauser, P.A.

Post Office Box 669

Tallahassee, FL 32302

John D.C. Newton, II

Suzanne Mann

Messer, Vickers, Caparello,

Madsen & Goldman, P.A.

Post Office Box 1876

Tallahassee, FL 32302-1876

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions to this recommended

order. All agencies allow each party at least ten days in which to submit

written exceptions. Some agencies allow a larger period within which to submit

written exceptions. You should contact the agency that will issue the final

order in this case concerning agency rules on the deadline for filing exceptions

to this recommended order. Any exceptions to this recommended order should be

filed with the agency that will issue the final order in this case.