16-003819CON East Florida-Dmc, Inc. vs. Agency For Health Care Administration
 Status: Closed
Recommended Order on Tuesday, April 30, 2019.


View Dockets  
Summary: When evaluated in the context of the applicable statutory and rule criteria, neither applicant for a new hospital in the Doral area of Dade County established need for its proposal.

1STATE OF FLORIDA

4DIVISION OF ADMINISTRATIVE HEARINGS

8EAST FLORIDA - DMC, INC.,

13Petitioner,

14vs. Case No. 16 - 3819CON

20AGENCY FOR HEALTHCARE

23ADMINISTRATION,

24Respondent,

25and

26CGH HOSPITAL, LTD, d/b/a CORAL

31GABLES HOSPITAL; TENET HIALEAH

35HEALTHSYSTEM, INC., d/b/a

38HI ALEAH HOSPITAL; LIFEMARK

42HOSPITALS, INC., d/b/a PALMETTO

46GENERAL HOSPITAL; AND THE PUBLIC

51HEALTH TRUST OF MIAMI - DADE

57COUNTY, FLORIDA, d/b/a JACKSON

61HOSPITAL WEST,

63Intervenors.

64_______________________________/

65THE PUBLIC HEALTH TRUST OF

70MIAMI - DADE COUNTY, FLORIDA,

75d/b/a JACKSON HOSPITAL WEST,

79Petitioner,

80vs. Cas e No. 16 - 3820CON

87AGENCY FOR HEALTHCARE

90ADMINISTRATION,

91Respondent,

92and

93KENDALL HEALTHCARE GROUP, LTD,

97d/b/a KENDALL REGIONAL MEDICAL

101CENTER; CGH HOSPITAL, LTD, d/b/a

106CORAL GABLE S HOSPITAL; TENET

111HIALEAH HEALTHSYSTEM, INC.,

114d/b/a HIALEAH HOSPITAL; AND

118LIFEMARK HOSPITALS, INC., d/b/a

122PALMETTO GENERAL HOSPITAL,

125Intervenors.

126_______________________________/

127RECOMMENDED ORDER

129Pursuant to notice, a final hearing was held in this case

140on September 10 through 14, 17 through 21 , and 24 through 26,

1522018, in Tallahassee, Florida, before W. David Watkins, the

161designated Administrative Law Judge of the Division of

169Administrative Hearings.

171APPEARANCES

172For The Public Health Trust of Miami - Dade County, Florida ;

183d/b/a Jackson Hospital West:

187Thomas F rancis Panza, Esquire

192Elizabeth L. Pederson, Esquire

196Paul C. Buckley, Esquire

200Angelina Gonzale z, Esquire

204Alec J. Zavell, Esquire

208Panza Maurer & Maynard, P.A.

2132400 East Commercial Boulevard , S uite 905

220Ft. Lauderdale, Florida 33308

224For East Florida - DMC, Inc. ; and Kendall Healthcare Group,

234Ltd, d/b/a Kendall Regional Medical Center:

240Stephe n A. Ecenia, Esquire

245Craig D. Miller, Esquire

249Gab riel F.V. Warren, Esquire

254Rutledge Ecenia, P.A.

257119 South Monroe Street, Suite 202

263Tallahassee, Florida 32301

266For Agency for Healthcare Administration:

271Richard Joseph Saliba, Esquire

275Kevin Michael Marker, Esquire

279Agency for Healthcare Administration

283Fort Knox Building III , Mail Stop 7

2902727 Mahan Drive

293Tallahassee, Florida 32308

296For CGH Hospital, Ltd , d/b/a Coral Gables Hospital ; Tenet

305Hialeah HealthSystem, Inc. , d/b/a H ialeah Hospital ; and Lifemark

314Hospitals, Inc. , d/b/a Palmetto General Hospital:

320Michael J. Glazer, Esquire

324Eugene Dylan Rivers, Esquire

328Stephen C. Emmanuel, Esquire

332Ausley & McMullen

335123 South Calhoun Street

339Tallahassee, Florida 32301

342STATEMENT OF TH E ISSUE S

348The issue s in th e s e case s are whether Certificate of Need

363(CON) Application No. 10432 filed by East Florida - DMC, Inc.

374(DMC) , to build an 80 - bed acute care hospital in Miami - Dade

388County, Florida, AHCA District 11, or CON Application No. 10433

398filed by T he Public Health Trust of Miami - Dade County, Florida

411d/b/a Jackson Hospital West (JW), to build a 100 - bed acute care

424hospital in Miami - Dade County, Florida, AHCA District 11, on

435balance, satisfy the applicable criteria ; and, if so, whether

444either or b oth should be approved.

451PRELIMINARY STATEMENT

453The proceeding involves two CON applications filed in the

462first batching cycle of 2016. Each applicant sought approval to

472build and operate an acute care hospital in the City of Doral

484within Miami - Dade County, Florida, AHCA District 11. CON

494Application No. 10432, filed by DMC, is for an 80 - bed hospital,

507and CON Application No. 10433, filed by JW, is for a 100 - bed

521hospital.

522Following its review of the two applications, the Agency

531for Healthcare Administration (Agency or AHCA) issued a State

540Agency Action Report (SAAR) recommending that both CON

548applications be denied. The SAAR was signed by Marisol Fitch,

558AHCAÓs health administration s ervices m anager.

565DMC and JW timely filed challenges to the preliminary

574denials of their applications, and AHCA referred their

582respective petitions to the Division of Administrative Hearings

590(DOAH) to conduct formal administrative hearings pursuant to

598sections 120.569, 120.57(1), and 408.039, Florida Statu t es. At

608DOAH, DMC and J WÓs petitions were assigned Case Nos. 16 - 3819CON

621and 16 - 3820CON, respectively, and the undersigned was designated

631as the Administrative Law Judge (ALJ) to conduct the

640proceedings. Variety ChildrenÓs Hospital , d/b/a Nicklaus

646ChildrenÓs Hospital (NCH) , file d a Petition for Leave to

656Intervene in each of the two proceedings , and three hospitals:

666CGH Hospital, Ltd., d/b/a Coral Gables Hospital (CGH); Tenet

675Hialeah Healthsystem, Inc., d/b/a Hialeah Hospital (Hialeah);

682and Lifemark Hospitals, Inc., d/b/a Palmet to General Hospital

691(PGH) (collectively the Tenet Hospitals or Tenet), filed a Joint

701Motion to Intervene in each of the two proceedings. JW filed a

713Motion to Intervene in DOAH Case No. 16 - 3819CON , and Kendall

725Healthcare Group, Ltd, d/b/a Kendall Regional Medical Center

733(KRMC) , filed a Motion to Intervene in DOAH Case No. 16 - 3820CON.

746On July 19, 2016, the undersigned entered an Order of

756Consolidation that consolidated DOAH Case Nos. 16 - 3819CON and

76616 - 3820CON (the consolidated cases). By July 20, 2016, th e

778undersigned had entered Orders in the consolidated cases that

787granted each of the outstanding petitions and motions to

796intervene.

797On July 20 , 2016 , NCH, CGH, Hialeah, and PGH filed an

808Amended Joint Unopposed Motion for Abeyance in Case No. 16 -

8193819CON. T he motion represented that the parties were then

829involved in four consolidated cases , DOAH Case Nos. 16 - 0112CON,

84016 - 0113CON, 16 - 0114CON, and 16 - 0115CON ( the Batch One

854Proceedings or the Batch One Case). The Batch One Proceedings

864involved the same party ap plicants, virtually the same CON

874applications (albeit in an earlier batching cycle, the second

883cycle in 2015) for the same proposed projects, and the same

894parties in opposition to the CON applications as these

903consolidated cases. The unopposed motion requ ested that the

912consolidated cases be placed in abeyance until 30 days after the

923issuance of the f inal o rder in the Batch One Proceedings. The

936motion also referred to JWÓs Motion to Intervene in Case No. 16 -

9493819 CON , and JWÓs slightly different request for relief that the

960matter be set for a 30 - day hearing beginning on or after July 1,

9752017, in order to allow for the issuance of a final order in the

989Batch One Proceedings. A similar but separate Joint Unopposed

998Motion for Abeyance was filed on July 19, 2016, by NCH, the

1010Tenet Hospitals, and JW in Case No. 16 - 3820CON. The partiesÓ

1022requests for relief were identical to the partiesÓ requests in

1032the Amended Joint Unopposed Motion filed in Case No. 16 - 3819 CON .

1046On July 20, 2016, the undersigned entered an Order Pl acing

1057Cases in Abeyance that granted the motions for abeyance filed in

1068each of the consolidated cases and ordered the parties to confer

1079and advise in writing no later than a certain date, as to the

1092status of the matter and the length of time required for t he

1105final hearing, and several mutually - agreeable dates for

1114scheduling the final hearing, should one be necessary. During

1123the abeyance, NCH filed a notice of voluntary dismissal of its

1134petitions in the consolidated cases on November 20, 2017, and

1144NCH did n ot participate in the proceedings thereafter.

1153Following a number of joint status reports and Orders

1162continuing the cases in abeyance, the parties filed a joint

1172status report on May 10, 2018. They reported that AHCA had

1183issued a Final Order in the Batch On e Cases that denied the CON

1197applications of both DMC and JW. 1/ A scheduling conference was

1208held with all parties and the consolidated cases were set for

1219hearing for 15 days the following September. The consolidated

1228cases proceeded to hearing as scheduled .

1235At the hearing, JW presented the testimony of the following

1245witnesses: Carlos Migoya, accepted as an expert in healthcare

1254administration; Peter Glen Paige, M.D., accepted as an expert in

1264hospital and healthcare administration and emergency medicine;

1271Ger alyn Lunsford, accepted as an expert in hospital

1280administration; Girish Bobby Kapur, M.D., accepted as an expert

1289in emergency medicine; Wilfredo Alvarez, accepted as an expert

1298in fire rescue and emergency medical services ( EMS ) ; Richard

1309Garcia, P.E., accep ted as an expert in transportation

1318engineering; Mark Knight, accepted as an expert in healthcare

1327finance and healthcare innovation; Michael Goldberg, M.D.,

1334accepted as an expert in anesthesiology and perioperative

1342services; Henry Iler, accepted as an exper t in urban planning

1353and land use; Armand Edward Balsano, accepted as an expert in

1364healthcare planning; David S. Levitt, accepted as an expert in

1374healthcare planning; Laura Hunter, accepted as an expert in

1383healthcare strategic planning and development; Juan Pablo

1390Zambrano, M.D., accepted as an expert in cardiology,

1398interventional cardiology, vascular medicine, and endovascular

1404medicine; and, Rick Knapp, accepted as an expert in healthcare

1414finance. JW offered the following exhibits which were received

1423into e vidence: Exhibits 1, 2, 5, 6, 8, 11, 13, 17 - 22, 39 - 43,

144045, 50 - 59, 62 - 64 , 67 - 75, 77 - 146, 149 - 151, 156, 162, 163, 167,

1460172, 209, 211 , and 229.

1465DMC and KRMC presented the testimony of the following

1474witnesses: Brandon Lee Haushalter, chief executive o fficer at

1483KRMC, accepted as an expert in healthcare and hospital

1492administration; Michael Joseph, p resident of Hospital

1499Corporation of AmericaÓs Florida division, accepted as an expert

1508in hospital and healthcare administration; Carlos Santiago,

1515M.D., accepted as a n expert in general surgery and robotic

1526surgery; Eduardo Franca, M.D., accepted as an expert in

1535interventional radiology; Mark McKenney, M.D., accepted as an

1543expert in surgery, surgical critical care and trauma;

1551Christopher Heggen, accepted as an expert in transportation

1559engineering; Braulio Sabates, M.D., accepted as an expert in

1568general surgery and laparoscopic surgery; Darryl Weiner,

1575accepted as an expert in healthcare finance; Katherine Platt,

1584accepted as an expert in health planning and health finance; and

1595Daniel J. Sullivan, accepted as an expert in healthcare planning

1605and finance. DMC and KRMC offered the following exhibits which

1615were received as evidence: Exhibit s 1 - 3, 13, 17, 18, 20 - 22,

163025 - 28, 33 - 36, 39, 42, 43, 46, 47, 85, 112, 114, 118, 130, 13 1,

1648and 143.

1650The Tenet Hospitals presented the testimony of the

1658following witnesses: Anna Mederos, an expert in nursing and

1667hospital administration; Christina Jimenez, accepted as an

1674expert in hospital administration; Jorge Perez, M.D., accepted

1682as an expe rt in pathology; and Patricia Greenberg, accepted as

1693an expert in healthcare planning and finance. Tenet offered the

1703following exhibits which were received as evidence: Exhibit s 1,

17132, 5, 6, 9 - 11, 14, 15, 17 - 54, 56 - 72, 91, 99, 107, and 124.

1732Official recognition was take n of Tenet Exhibits 108 - 111

1743and 115.

1745Consistent with the announcement made at the outset of the

1755hearing that, ÐAHCA is not taking a position at this hearing on

1767the applications and does not intend to present evidence in the

1778proceeding,Ñ the Agency did not present the testimony of any

1789witnesses and offered no exhibits.

1794The 24 - volume T ranscript of the final hearing was filed

1806with DOAH on November 2, 2018. Thereafter the parties timely

1816filed their respective Proposed Recommended O rders, each o f

1826which has been carefully considered in the preparation of this

1836Recommended Order.

1838All references to Florida Statutes are to the 2018 version

1848unless indicated otherwise.

1851P REFACE TO FINDINGS OF FACT

1857As stipulated by the parties, at issue in this proceeding

1867are the CON applications filed in the first batching cycle of

18782016 . The parties stipulated that the Batch One Proceedings

1888involved the same party applicants, virtually the same CON

1897applications (albeit in an earlier batching cycle, the second

1906cycle in 20 15), for the same proposed projects, and the same

1918parties in opposition to the CON applications as these

1927consolidated cases. Given the similarity of the two

1935applications, the issues to be determined in both cases, and the

1946evidence presented (often by witn esses that also testified in

1956the Batch One hearing), the undersigned notes that many of the

1967Findings of Fact in the instant proceeding are similar to the

1978Findings of Fact made in the Batch One Recommended Order.

1988However, pursuant to section 120.57(1)(k), the hearing conducted

1996by the undersigned was de novo , and the Findings of Fact set

2008forth below are based upon the evidence adduced at hearing, as

2019well as the entire record of this proceeding as defined by

2030section 120.57(1)(f). 2/

2033FINDING S OF FACT

2037Based upon the partiesÓ stipulations, the demeanor and

2045credibility of the witnesses, other evidence presented at the

2054final hearing, and on the entire record of this proceeding, the

2065following Findings of Fact are made:

2071I. The Parties

2074The Public Health Trust of Miami - Dade County d/b/a Jackson

2085Hospital West and Jackson Health System (JHS)

20921 . JHS is a taxpayer - funded health system located in and

2105owned by Miami - Dade County. It is governed by The Public Health

2118Trust of Miami Dade - County, Florida (PHT), a seven - member b oard.

2132JHS owns and operates three acute care hospitals in Miami - Dade

2144County -- Jackson Memorial Hospital (JMH) ; Jackson North Medical

2153Center (JN) ; and Jackson South Medical Center (JS) -- as well as

2165three specialty hospitals: Holtz ChildrenÓs Hospital (Holtz );

2173Jackson Rehabilitation Hospital; and Jackson Behavioral Health

2180Hospital. JHS also owns and operates numerous other non -

2190hospital healthcare facilities within Miami - Dade County. JHSÓs

2199applicant in this proceeding is JW which, if approved, will be

2210anothe r acute care hospital in JHS.

22172 . JHS is an academic teaching institution, and the

2227University of Miami (UM) is JHSÓs affiliated medical school.

2236Over 1,000 UM residents staff JMH pursuant to an operating

2247agreement with JHS. JN and JS are not academic medi cal centers.

22593 . JHS annually receives sales tax and ad valorem tax

2270revenues from Miami - Dade County in order to help fund its

2282operations.

22834 . JS and JN are community hospitals operated as part of

2295JHS. JS was acquired in 2001. JS is licensed for 226 beds and

2308is also home to a verified Level II trauma center.

23185 . The JN facility was acquired by JHS in 2006. The

2330facility is licensed for 382 beds.

2336East Florida (DMC)

23396 . DMC is an affiliate of HCA Healthcare, Inc. (HCA), the

2351largest provider of acute care ho spital services in the world.

2362DMC will operate within HCAÓs East Florida Division (EFD), which

2372is comprised of 15 hospitals, 12 surgery centers, two diagno stic

2383imaging centers, four free standing emergency departments, nine

2391behavioral health facilities , an d one regional laboratory, along

2400with other related services. There are thre e HCA - affiliated

2411hospitals in Miami - Dade County: KRMC; Aventura Hospital and

2421Medical Center (Aventura); and Mercy Hospital, a campus of

2430Plantation General Hospital (Mercy).

2434Kendall Regional (KRMC)

24377 . KRMC, which is located at the intersection of the

2448Florida Turnpike and S outhwest 40th Street in Miami - Dade County,

2460is a 417 - bed tertiary provider compr ised of 380 acute care beds,

247423 inpatient adult psychiatric beds, eight Level II n eonatal

2484intensive care unit (NICU) beds, and five Level III NICU beds.

2495It is a Baker Act receiving faci lity. KRMC is a verified

2507Level I trauma center. It also has a burn program.

25178 . KRMC is also an academic teaching facility, receiving

2527freestanding institutional accreditation from the Accrediting

2533Council for Graduate Medical Education (ACGME) in 2013. KRMC

2542currently has six residency programs including, among others,

2550surgery, internal medicine, podiatry, anesthesia, and surgical

2557critical care. Its tea ching programs are affiliated with the

2567University of South Florida, Nova Southeastern University, and

2575Florida International University. KRMC also participates in

2582scholarly and clinic al research.

25879 . In 2017, KRMC had over 82,000 Emergency Department (ED)

2599visits. It treated over 115,000 total inpatients and

2608outpatients that year. There are 850 physicians on KRMCÓs

2617medical staff. It offers a full range of medical surgery

2627services, interventional procedures, obstetrics (OB) , pediatric ,

2633and neonatal care, a mong many other service lines.

264210 . KRMC primarily serves southern and western portions of

2652Miami - Dade County but also receives referrals from the Florida

2663Keys up through Broward County, Palm Beach County , and the

2673Treasure Coast. Its main competitors inclu de, but are not

2683limited to: Baptist Hospital; Baptist West; South Miami

2691Hospital; PGH; Hialeah; CGH; JS , and Palm Springs General

2700Hospital.

2701The Tenet Hospitals

270411 . PGH, Hialeah, and CGH are wholly - owned subsidiaries of

2716Tenet South Florida. These are al l for - profit hospitals.

272712 . PGH is a 368 - bed tertiary facility that opened in the

2741early 1970s. It has 297 licensed acute care beds, 48 adult

2752psychiatric beds, 52 ICU beds, and 15 Level II NICU beds. It is

2765located at the Palmetto Expressway and Northwest 122nd Street in

2775Hialeah, Florida . The hospital employs about 1,700 people and

2786has over 600 physicians on its medical staff.

279413 . PGH is a tertiary - level facility offering a variety of

2807specialty services , including adult open heart surgery, a

2815comprehensiv e stroke center, and robotic surgery. It has

2824inpatient mental health beds and serves the community as a Baker

2835Act receiving facility. It also offers OB and Level II NICU

2846services with approximately 1,500 births a year. It has

2856approximately 70,000 ED vis its and between 17,000 and 18,000

2869inpatient admissions per year. In addition to its licensed

2878inpatient beds, PGH operates 31 observation beds.

288514 . PGH is ACGME accredited and serves a significant

2895teaching function in the comm unity. It has approximately

290489 residents and fellows. The hospital provides fellowships in

2913cardiology, critical care and interventional cardiology, and

2920also has rotations in neurology and gastroenterology. Residents

2928from Larkin General Hospital also rotate through PGH.

293615 . PGH gen erally serves the communities of Opa Locka,

2947Hialeah, Miami Lakes, Hialeah Gardens, Doral , and Miami Springs.

2956In reality, all of the hospitals in the county are competitors,

2967but more direct competition comes from Palm Springs Hospital,

2976Memorial in Miramar, Mount Sinai, Kendall, and even its sister

2986hospital, Hialeah.

298816 . Hialeah first opened in 1951 and is a 378 - bed acute

3002care facility. It has 356 acute care beds, 12 adult psychiatric

3013beds, and 10 Level II NICU beds. The ED has 25 beds and about

302740,000 vi sits per year. It has approximately 14,000 inpatient

3039admissions and 1,400 babies delivered annually. It offers

3048services including cardiac, stroke, robotic surgery, colorectal

3055surgery, and OB services. The hospital has a Level II NICU with

306712 beds.

306917 . CGH is located in the City of Coral Gables and is near

3083the border between Coral Gables and the City of Miami on Douglas

3095Road. It first opened in 1926. Portions of the original

3105structure are still in use.

311018 . CGH has 245 license d beds, over 725 employees ,

3121367 physicians, and over 100 additional allied providers on its

3131medical staff. The hospital has a full - service ED. Its service

3143lines include general surgery, geriatrics, urology, treatment of

3151cardiovascular and pulmonary disease, and others. The hospi tal

3160has eight operating rooms and offers robotic surgery. The ED

3170has 28 beds divided into the main area and a geriatric emergency

3182room. It had about 25,000 ED visits last year, which is lower

3195than prior years, due in part to the presence of over a dozen

3208nearby urgent care centers.

321219 . CGH has over 8,500 inpatient admissions per year and

3224is not at capacity. While patient days have grown slightly, the

3235average occupancy is still just a little over 40%, meaning, on

3246average, it has over 140 empty inpatient beds on any given day.

3258The hospital is licensed for 245 beds, but typically there are

3269only 180 beds immediately available for use.

3276Agency for Healthcare Administration (AHCA)

328120 . AHCA is the state health - planning agency charged with

3293administration of th e CON program as set forth in sections

3304408.31 - 408.0455, Florida Statutes.

3309II. The Proposals

3312Doral Medical Center (DMC)

331621 . DMC proposes to build an 80 - bed community hospital

3328situated within the residential district of Doral. The hospital

3337will be locate d in southwestern Doral in z ip c ode 33126 and will

3352serve the growing population of Doral, along with residential

3361areas to the north and south of Doral.

336922 . The hospital will be located in the City of DoralÓs

3381residential district on Northwest 41 st Street b etween Northwest

3391109th Avenue to the east, and Northwest 112th Avenue to the

3402west. Doral has seen significant growth in the past 15 years

3413and has been consistently included on the list of the fastest

3424growing cities in Florida.

342823 . The new facility w ill have a bed complement of

344080 licensed acute care beds , inc luding 72 medical/surgical and

3450eight OB beds. The proposed acute care hospital will be fully

3461accredited by t he Joint Commission for the Accreditation of

3471Healthcare Facilities and licensed by the Sta te of Florida. No

3482public funds will be utilized in construction of the hospital

3492and it will contribute to the s tate, c ounty, and m unicipal tax

3506base as a proprietary corporation.

351124 . DMC will offer a full range of non - tertiary services,

3524including emergency services, imaging, surgery, intensive care,

3531cardiac catheterization , and women's services, including an OB

3539unit, and pediatric care. DMC will be a general medical

3549facility that will include a general medical component and a

3559surgery component. Althoug h DMC will operate an OB unit, NICU

3570services will not be offered at DMC. If DMCÓs patients need

3581more advanced services, including NICU, the EFD hopes they will

3591receive them from KRMC. The open medical staff will be largely

3602community - based, but University of Miami physicians would be

3612welcome at DMC.

361525 . Before the hospital is built, KRMC will construct and

3626operate a freestanding emergency department (FSED) at the

3634location that will eventually become the ED of DMC.

3643Construction of the FSED is now underwa y, and Brandon

3653Haushalter, chief executive officer ( CEO ) of KRMC, estimate d

3664that it will open in March or April of 2019.

3674Jackson West

367626 . JHS proposes to build a community hospital to be known

3688as ÐJackson WestÑ near the eastern edge of Doral. The propo sed

3700100 - bed general acute care hospital would have medical surgical

3711and obstetrical beds and offer basic acute care services.

372027 . JHS is a public health system owned by Miami - Dade

3733County. All of JHSÓs assets, as well as its debts, belong to

3745the c ounty. JHS is a not - for - profit entity, and therefore does

3760not pay taxes, though it receives hundreds of millions of

3770dollars from property taxes and sales taxes in Miami - Dade

3781County.

378228 . JHSÓs main campus is a large health campus located

3793near the Midtown Miami a rea in between Allapattah (to the north)

3805and Little Havana (to the south). In addition to JMH, the

3816campus includes Holtz ChildrenÓs Hospital, a behavioral health

3824hospital, an inpatient rehabilitation hospital, and several

3831specialty clinics. Bascom - Palmer Eye Institute, a Veterans

3840Administration hospital, and University of Miami Hospital are

3848also located adjacent to Jackson West Ós main campus.

385729 . JMH is a 1 , 500 - bed hospital with a wide array of

3872programs and services, including tertiary and quaternary ca re,

3881and a Level I trauma program, the Ryder Trauma Center. JMH

3892receives patients from throughout Miami - Dade County, elsewhere

3901in Florida, and internationally.

390530 . JMH is a teaching hospital and has a large number of

3918residents , as well as professors from the University of Miami ,

3928on staff. UM and JMH have had a relationship for many years,

3940and in addition to research and teaching, UM provides physician

3950staffing to JMH.

395331 . JN is a 342 - bed community hospital located in between

3966Miami Gardens and North Miam i Beach, just off of I - 95 and the

3981Turnpike.

398232 . JS is a 252 - bed community hospital located in the

3995Palmetto Bay area just south of Kendall. It has stroke

4005certification and interventional cardiology, and was recently

4012approved for a trauma program, which b egan in May 2016.

402333 . Both JN and JS were existing hospitals that were

4034acquired by JHS. JHS has never built a hospital from the ground

4046up.

404734 . In 2014, JHS leadership directed its internal planning

4057team to review the healthcare needs of county residents . JHSÓs

4068analysis identified a need for outpatient services in western

4077Miami - Dade, the only remaining quadrant of the c ounty in which

4090JHS did not have a hospital or healthcare program at the time.

4102As part of its due diligence, JHS then consulted healthcar e firm

4114Kurt Salmon & Associates (KSA) to independently evaluate the

4123data. KSAÓs investigation validated a need in the west county

4133for adult and pediatric outpatient services, including need for

4142a n FSED. This prompted JHS to explore opportunities for

4152expansion of outpatient services where needed: in the western

4161corridor of Miami - Dade. This was also the genesis of JHSÓs

4173long - range plan to first build a n FSED in the Doral area, to be

4189followed ultimately by the addition of a general acute care

4199hospital at t he site.

420435 . The JW site is a 27 - acre parcel of land located just

4219west of the Palmetto Expressway and north of 25th Street. The

4230site is in an industrial area only a short distance from the

4242western end of the runways at Miami International Airport. The

4252site is located in zip code 33122, which is very sparsely

4263populated.

426436 . JW proposed a primary service area (PSA) consisting of

4275zip c odes 33126, 33144, 33166, 33172/33122, 33174, 33178,

4284and 33182, and a secondary service area (SSA) of zip

4294codes 33155, 331 65, 33175, and 33184. JW intends to serve

4305general, acute care non - tertiary patients and OB patients.

4315Detailed below, trends in the JW service area do not demonstrate

4326need for its proposed hospital.

433137 . The location of the JW site will not contribute to the

4344viability of the proposed hospital. According to 2010 census

4353data, only 328 people live within a one - mile radius of the JW

4367site. Since 2000, only 32 total people have moved into that

4378same area around the JW site -- an average of three per year.

4391There are virtually no residences within a one - mile radius of

4403the JW site. From 2000 to 2010, the population within a two -

4416mile radius of the JW site decreased by a rate of 9.4%.

442838 . The JW health planner projects JWÓs home zip c o de

4441of 33122 will have a total p opulation of only eight (8) people

4454in 2022.

445639 . From 2012 to 2014, the use rate in the JW service area

4470for non - tertiary patients decreased by 3.9%. That decline

4480continued at a steeper pace of 4.2% from 2014 to 2017. This was

4493largely due to the 65 age c ohort, the demographic of patients

4505that utilize inpatient services the most. The 65 age cohort is

4516growing at a slower pace in the JW service area than in Miami -

4530Dade or Florida as a whole. Non - tertiary discharges in the JW

4543service area are declining at a greater pace than that of Miami -

4556Dade County -- negative 4.2% compared to negative 1.9%.

456540 . The rate of projected population growth in the JW PSA

4577is decreasing. The projected rate of growth for the JW service

4588area is lower than that of Miami - Dade County a nd Florida as a

4603whole. The OB patient base JW intends to rely on is projected

4615to remain flat.

461841 . The inpatient discharges for all ages in the JW

4629service area have declined from 2014 to 2017. For ages 0 - 17,

4642discharges in the JW service area declined 21. 4% during that

4653time period. The discharges for ages 18 - 44 declined by 4.8%,

4665and the discharges for ages 45 - 64 declined by 8.9%. The

4677discharges for the important 65 age cohort declined by 0.1%.

4687Specifically, the discharges for ages 65 - 74 declined by 6.5 %,

4699and the discharges for ages 75 - 84 declined by 3.3%. The

4711discharges for ages 85 are the only age cohort that has not

4723declined from 2012 to 2017. Overall, the non - tertiary

4733discharges per 1,000 population (i.e., use rate) for all ages in

4745the JW service area declined from 2012 to 2014 by 6% , and from

47582014 to 2017 by 7.8%.

476342 . Despite these declines in discharges in the JW service

4774area, the health planners who crafted the JW projections used a

4785constant use rate for the 0 - 17, 18 - 44, and 45 - 64 age cohorts.

4802The JW health planners used a declining use rate for the 65 age

4815cohort. These use rates were applied uniformly across all zip

4825c odes, despite wide variance in actual use rates in each zip

4837c ode.

483943 . Applying the zip code specific use rates in

4849conjunction with the other assumptions used by the JW health

4859planner demonstrates that the JW projections are unreasonable.

4867For instance, JWÓs reliance on a uniform use rate over - projects

4879the number of discharges in JW PSA zip c ode 33178 by nearly

48921,000 patients. T his occurs because the population is only

4903growing at a 2% rate in the zip code, but JWÓs reliance on

4916service area - wide projections cause the discharges to grow at an

4928extraordinary rate of 8.9% per year. Applying actual use rates

4938across all zip codes cause s a drastic change in the JW PSA and

4952SSA definition.

495444 . Section 408.037(2) requires a CON applicant to

4963identify its PSA and SSA by listing zip codes in which it will

4976receive discharges in descending order, beginning with the zip

4985code with the highest amo unt of discharges, then proceeding in

4996diminishing order to the zip code with the lowest amount of

5007discharges. The zip codes , which comprise 75% of discharges ,

5016constitute the PSA ; and the remaining zip codes, which consist

5026of the remaining 25% of discharge s, makes up the SSA. However,

5038JW did not project its utilization in this manner.

504745 . In its application, JW did not define its service

5058area, PSA, and SSA zip codes in descending order by number or

5070percentage of discharges. When this correct adjustment i s made,

5080its PSA consists of zip c odes 33126, 33172, 33178, 33174, 33144,

5092and 33165; and its SSA consists of zip codes 33175, 33166,

510333155, 33182, and 33184. Z ip c odes 33166 and 33182 were in the

5117original JW PSA, and zip c ode 33165 was in the original JW S SA.

5132As such, JWÓs home zip code should actually be in its SSA. JW

5145health planners call this illogical, but it demonstrates that

5154the JW site is located within a zip code that has almost no

5167population of potential patients.

517146 . JHS is developing a n FSE D and outpatient/ambulatory

5182facilities on the JW site regardless of whether its CON

5192application for a hospital is approved. Construction has begun

5201on the JW site, and JHS is actually building a Ðshelled inÑ

5213structure intended to house a future hospital, n otwithstanding

5222lack of CON approval for the hospital. There is no contingency

5233plan for use of the shelled - in hospital space if CON approval is

5247not obtained. JHS executives unequivocally stated that they

5255intend to continue pursuing CON approval for the JW hospital,

5265even if the proposed DMC hospital is approved. Indeed, JHS has

5276filed third and fourth CON applications for its proposed JW

5286hospital.

528747 . The budget for the JW campus is $252 million. Sixty

5299to $70 million is being funded from a bond issuance a pproved by

5312voters in Miami - Dade County. Notably, the bond referendum

5322approved by voters made no mention of a new hospital. The

5333remaining $180 to $190 million is being funded by JHS, which has

5345chosen to only keep 50 days cash - on - hand, and put any surplus

5360toward capital projects. This is wel l below the number of days

5372cash - on - hand ws advisable for a system like JHS.

538448 . The specific programs and services to be offered at JW

5396have not been finalized, but it is clear that JW will be a small

5410community hospital that will not offer anything unique or

5419different from any of the existing hospitals in the area, nor

5430will it operate NICU beds. Patients presenting to JW in need of

5442specialized or tertiary services will need to be transferred to

5452another hospital with the capability of serving them, most

5461likely JMH.

5463III. The ApplicantsÓ Arguments

5467Doral Medical Center (DMC)

547149 . DMCÓs arguments in support of its proposed hospital

5481may be summarized as follows:

5486(1) Geographic features surrounding Doral

5491create transportation access barriers for

5496the residents of the area;

5501( 2 ) Doral is a densely - populated community

5511that is growing quickly and lacks a readily

5519accessible hospital;

5521( 3 ) KRMC, which is the provider of choice

5531for Doral residents, is a growing tertiary

5538facilit y that cannot sufficiently expand to

5545meet its future demands. DMC will serve

5552much of the same patient population

5558currently served by KRMC and help decompress

5565KRMCÓs acute care load so KRMC can focus on

5574its tertiary service lines;

5578(4) From a geographic standpoint, the Doral

5585community and its patients are isolated from

5592much of Miami - Dade County to the north,

5601west, and east, and the nearest hospitals.

560850 . East Florida - DMC is a subsidiary of HCA and would be a

5623part of the HCA EFD. Michael Joseph is the p resident of the

5636EFD, which includes 15 hospitals and other facilities from Miami

5646north through the Treasure Coast.

565151 . Mr. Joseph authorized the filing of the DMC CON

5662application, which proposes an 80 - bed basic acute care hospital

5673that includes 72 medica l surgical and eight OB beds. As noted,

5685there will be neither unique services at DMC nor any tertiary

5696services , such as a NICU. HCA anticipates that DMC patients

5706needing tertiary services would be referred and treated at KRMC.

571652 . The proposed hospital would be built on 41st Street,

5727between Northwest 109 th Avenue and Northwest 112 th Avenue. This

5738site is located on the western edge of Doral, just east of the

5751Everglades.

575253 . When the consultants were retained to write the first

5763DMC CON application, HCA h ad already made the decision to go

5775forward with the project.

577954 . Mr. Joseph described Miami - Dade County as one of the

5792most competitive markets in the country for hospital services.

5801There is robust competition in the Miami - Dade market from the

5813standpoints of payors, physicians, and the many hospitals

5821located in the county, including Jackson, HCA, Tenet, Baptist

5830and others.

583255 . HCA is not proposing this project because any of the

5844existing hospitals in the area do not provide good quality care.

585556 . HCA is currently building a n FSED on the DMC site that

5869will open regardless of whether the DMC hospital is approved.

587957 . Mr. Joseph acknowledged that there is a trend toward

5890outpatient rather than inpatient care. Inpatient occupancy of

5898acute care hospitals in Miami - Dade County has been declining in

5910recent years. Managed care has added further pressure on

5919reducing inpatient admissions.

592258 . Surgical advances have also resulted in fewer

5931inpatient admissions. Surgeries that formerly required an

5938inpatient stay a re now often done on an outpatient basis.

594959 . Mr. Joseph agreed that 30 minutes is a reasonable

5960travel time to access an acute care hospital.

596860 . The home zip code for the proposed DMC hospital is

598033178. KRMCÓs market share for that zip code is 20 % .

5992Individuals in that zip code are currently accessing a wide

6002variety of hospitals. PGH is only 6.7 miles away and has the

6014fourth highest market share in that zip code.

602261 . HCAÓs healthcare planning expert, Dan Sullivan,

6030acknowledged that, if approved, DMC would likely have an adverse

6040financial impact on KRMC and other area hospitals.

604862 . Several witnesses testified that the travel time from

6058the DMC site to KRMC is about 10 minutes, and that an ambulance

6071could do it in as little as five minutes.

608063 . As t o the argument that the residents of Doral face

6093geographic access barriers, the evidence did not indicate that

6102there is anything unique about Doral from a traffic standpoint

6112compared to other parts of Miami - Dade County. People come in

6124and out of Doral on a daily basis in significant numbers for

6136work and other reasons via various access points.

614464 . Witnesses agreed that 25 to 30 minutes is a reasonable

6156drive time for non - tertiary acute care services, and the

6167evidence showed that residents of Doral, and the DMC service

6177area, are well within 30 minutes of multiple hospitals providing

6187more intensive services than are proposed by DMC. Indeed, many

6197residents of DMCÓs service area are closer to other hospitals

6207than to the DMC site.

621265 . None of the DMC witnesses were able to identify any

6224patient in Doral who had been unable to access acute care

6235services, or had suffered a bad outcome because of travel from

6246Doral to an area hospital. The evidence did not establish that

6257there currently exists either geographic or financial access

6265barriers within the service area proposed to be served by DMC.

6276Jackson West

627866 . As in its Batch One application, J W advances six

6290arguments as to why its proposed hospital should be approved.

6300They are:

63021) It will serve a significant amo unt of

6311indigent and Medicaid patients.

63152) JHS already serves residents of the

6322proposed service area, which JW

6327characterizes as Ðfragmented , Ñ in that

6333residents go to a number of different

6340hospitals to receive services.

63443) Development of the freestanding ED and

6351ambulatory center is under way.

63564) JW would provide an additional

6362opportunity to partner with UM and FIU.

63695) There is physician and community support

6376for the project.

63796) JW will add to the financial viability

6387of JHS and its ability to continu e its

6396mission.

639767 . JW presented very little analysis of the types of

6408factors typically considered in evaluating need for a new

6417hospital. JW did not discuss existing providers and their

6426programs and services, the utilization of existing hospitals ,

6434and wh ether they have excess capacity, or other important

6444considerations. Instead, JW advanced the six arguments noted

6452above, for approval of its proposed hospital, none of which

6462truly relate to the issue of need.

646968 . First, JW states that its proposed hospita l will serve

6481a significant level of Medicaid and indigent patients. While it

6491is true that JHS serves a significant amount of Medicaid and

6502indigent patients, there are a number of reasons why this is not

6514a basis to approve its proposed hospital.

652169 . As an initial matter, JW treads a fine line in touting

6534its service to Medicaid and indigent patients, while also

6543targeting Doral for its better payer mix and financial benefit

6553to JHS. JHS also receives an enormous amount of tax dollars to

6565provide care to indig ent and underserved patients. While other

6575hospitals in Miami - Dade County provide care to such patients,

6586they do not receive taxpayer dollars, as does JHS, although they

6597pay taxes, unlike JHS. Also, Medicaid is a good payer for JHS.

6609With its substantial supplement, JHS actually makes money from

6618Medicaid patients, and it costs the system more for a Medicaid

6629patient to be treated at a JHS hospital than elsewhere. More

6640significantly, there is not a large Medicaid or indigent

6649population in Doral, nor evidenc e of financial access issues in

6660Doral.

666170 . Second, JW argues that its CON application should be

6672approved because JHS already serves patients from the Doral

6681area, which JW characterizes as ÐfragmentedÑ because area

6689residents go to several different hospita ls for care. This so -

6701called ÐfragmentationÑ is not unique to Doral, and is not

6711unusual in a densely - populated urban market with several

6721existing hospitals. The same phenomenon occurs in other areas

6730of Miami - Dade County, some of which actually have a hosp ital in

6744the localized area. The fact that Doral residents are accessing

6754several different hospitals demonstrates that there are a number

6763of existing providers that are accessible to them. As discussed

6773in greater detail below, residents of the Doral area have

6783choices in every direction (other than to the west, which is the

6795Everglades). JHS itself already serves patients from the Doral

6804area. If anything, this tells us that patients from Doral

6814currently have access to the JHS hospitals.

682171 . Third, JW argu es that its CON application should be

6833approved because development of the JW campus is under way.

6843This is irrelevant to the determination of need, and is simply a

6855statement of JHSÓs intent to build a n FSED and outpatient

6866facilities on a piece of land that was acquired for that

6877purpose, regardless of CON approval.

688272 . Fourth, JW argues for approval of its proposed

6892hospital because it would provide an additional opportunity to

6901partner with UM and Florida International University ( FIU ) .

6912However, the statuto ry criteria no longer address es research and

6923teaching concerns, and JHSÓs relationship with UM or FIU has no

6934bearing on whether there is a need for a new hospital in the

6947Doral area. Moreover, JW did not present any evidence of how it

6959would partner with UM or FIU at JW, and there does not seem to

6973be any set plans in this regard.

698073 . Fifth, JW claims that there is physician and community

6991support for its proposed hospital, but it is very common for CON

7003applicants to obtain letters in support for applications .

7012Indeed, the DMC application was also accompanied by letters of

7022support.

702374 . Sixth and finally, JW argues that its proposed

7033hospital will add to the financial viability of HSA and allow it

7045to continue its mission. However, JW provided no analysis of

7055the projected financial performance of its proposed hospital to

7064substantiate this. The only financial analysis in the record is

7074from KSA, a consulting firm that JHS hired to analyze the

7085programs and services to be developed at JW. The KSA analysis

7096posits th at the JW FSED project will lose millions o f dollars

7109and not achieve break - even unless there is an inpatient hospital

7121co - located there so that JW can take advantage of the more

7134lucrative hospital - based billing and reimbursement.

714175 . The sixth ÐneedÑ arg ument relates to the issue of

7153JHSÓs historical financial struggles, which bear discussion.

7160Only a handful of years ago, the entire JHS was in dire

7172financial trouble, so much so that selling all or parts o f it

7185was considered. Days cash - on - hand was in the single digits, and

7199JHS fell out of compliance with bond covenants.

720776 . JHSÓs financial difficulties prompted the appointment

7215of an outside monitor to oversee JHSÓs finances. Price

7224Waterhouse served in that role, and made several recommendations

7233for J HS t o improve its revenue cycle, make accounting

7244adjustments, and improve its staffing and efficiency. As a

7253result of these recommendations, JHS went through a large

7262reduction in force, and began to more closely screen the income

7273and residency of its patients . As a result of these measures ,

7285overall financial performance has since improved.

729177 . Despite its improved financial position, JHS still

7300consistently loses money on opera tions, including a

7308$362,000,915 loss as of June 30, 2018. JHS clearly depends upon

7321the hundreds of millions of non - operating tax - based revenues it

7334receives annually.

733678 . JHSÓs CEO expressed concerns over decreases in the

7346systemÓs non - operating revenue sources, and claimed that JHS

7356needs to find ways to increase its operating revenue to offset

7367this. JW is being proposed as part of this strategy. However,

7378JHSÓs chief financial o fficer testified that Ðthe non - operating

7389revenues are a fairly stable source of income.Ñ In fact, JHSÓs

7400tax revenues have gone up in the last few years.

741079 . JH S sees the more affluent Doral area as a source of

7424better paying patients that will enhance the profitability of

7433its new hospital. Beyond this aspiration however, there is no

7443meaningful analysis of the anticipated financial performance of

7451its proposed hos pital. This is a glaring omission given that a

7463significant impetus for spending millions of public dollars on a

7473new hospital is to improve JHSÓs overall financial position.

748280 . The KSA analysis referenced above determined that

7491changes to the Hospital Out patient Prospective Payment System

7500rule would result in the JW campus losing hundreds of millions

7511of dollars and never reaching Ðbreak even , Ñ absent an inpatient

7522hospital on the campus for Ðhospital basedÑ billing and

7531reimbursement.

753281 . Though a financia l benefit to the system, the

7543increased reimbursement JHS would receive by having an inpatient

7552hospital on the JW campus would be a financial burden on the

7564healthcare delivery system since it would cost more for the same

7575patient to receive the same outpatie nt services in a hospital -

7587based facility.

758982 . Reports by KSA also state that a strategic purpose of

7601JW is to attract patients that would otherwise go to nearby

7612facilities like PGH and Hialeah, and to capture tertiary or

7622higher complexity cases which would then be sent to JMH. JW Ós

7634witnesses and healthcare planning experts fully expect this to

7643happen.

764483 . I n 2015, and again in 2017, JHS conducted a ÐCommunity

7657Health Needs Assessment,Ñ which is required by law to be

7668performed by public safety net hospitals . The assessments were

7678conducted by gathering responses to various questions from a

7687wide array of community leaders and stakeholders, including the

7696CEOs of JHSÓs hospitals, about the healthcare needs of the

7706community.

770784 . The final Community Health Needs Assessment documents

7716are lengthy and cover a variety of health - related topics, but

7728most notable for this case is that: (1) nowhere in either the

77402015 or 2017 assessment is the development of a new hospital

7751recommended; and (2) expansion into western Miam i - Dade County

7762scored by far the lowest on a list of priorities for JHS.

777485 . In its application and at hearing, JW took the

7785position that JW can enter the Doral area market without

7795impacting existing providers to any meaningful extent. While JW

7804acknowledg es that its proposed hospital would impact the Tenet

7814H ospitals, it argues that the impact is not significant.

782486 . The evidence established that the financial impact to

7834the Tenet H ospitals (calculated based upon lost contribution

7843margin) would total roughl y $3 million for lost inpatients, and

7854$5.2 million including lost outpatients. While these losses

7862will not put the Tenet Hospitals in financial peril, they are

7873nonetheless significant and material.

7877The Existing Healthcare Delivery System

788287 . Miami - Dade County is home to 18 freestanding acute

7894care hospitals, comprising a total of 7,585 licensed and

7904approved acute care beds. With an average annual occupancy of

791453.8% in calendar year 2017, there were, on average,

7923approximately 3 , 500 unoccupied acute care beds in the county on

7934any given day. While the countywide occupancy rate fluctuates

7943from year to year, it has been on a downward trend in the past

7957several years.

795988 . As pointed out by several witnesses, the lack of a

7971hospital in Doral is not itself an in dication of need. In

7983addition, population growth, and the demands of the population

7992for inpatient hospital beds, cannot be considered in a vacuum.

8002Sound healthcare planning requires an analysis of existing area

8011hospitals, including the services they offe r and their

8020respective locations; how area residents travel to existing

8028hospitals and any barriers to access; the utilization of

8037existing hospitals and amount of capacity they have; and other

8047factors which may be relevant in a given case.

805689 . The populat ion of Doral currently is only about

806759 ,000 people. It is not as densely populated as many areas of

8080Miami - Dade County, has a number of golf course communities, and

8092is generally a more affluent area with a higher average

8102household income than much of Miami - Dade County. As set forth

8114in JWÓs CON application, the better payer mix in Doral was a

8126significant factor behind its decision to file its CON

8135application.

813690 . Although there is not a hospital within the Doral city

8148limits, there are a number of healthca re providers in Doral and

8160several hospitals nearby. PGH and Palm Springs Hospital are

8169just north of Doral. KRMC is just south of Doral. Hialeah is

8181northeast of Doral. CGH, Westchester General, and NCH are

8190southeast of Doral. JMH and all of its facilit ies are east of

8203Doral. And there are others within reasonable distance. KRMC

8212is only six miles due south of the proposed DMC site, and PGH is

8226just eight miles north of the DMC site. As to the JW site, PGH

8240is 6.9 miles distant, CGH is 8.6 miles distant, and Hialeah is

82527.4 miles distant.

825591 . Residents of the Doral area have many choices in

8266hospitals with a wide array of services, and they are accessing

8277them. The parties to this case, as well as other existing

8288hospitals, all have a share of the Doral ar ea market. JW calls

8301this ÐfragmentationÑ of the market and casts it in a negative

8312light, but the evidence showed this to be a normal phenomenon in

8324an urban area like Miami , with several hospitals in healthy

8334competition with each other.

833892 . Among the expe rts testifying at the hearing, it was

8350undisputed that inpatient acute care hospital use rates are on

8360the decline. There are different reasons for this, but it was

8371uniformly recognized that decreasing use rates for inpatient

8379services, and a shift toward ou tpatient services, are ongoing

8389trends in the market. Recognizing the need for outpatient

8398services in the Doral area, both JW and DMC (or, more

8409accurately, their related entities) have proposed outpatient

8416facilities and services to be located in Doral.

8424Kendall Regional Medical Center

842893 . KRMC is currently the dominant hospital provider in

8438the Doral area. Regarding his motivation for filing the DMC

8448application, Mr. Joseph readily admitted ÐitÓs as much about

8457protecting what I already currently provide, num ber one.Ñ

846694 . KRMC treats Medicaid and indigent patients. KRMC has

8476never turned away a patient because it did not have a contract

8488with a Medicaid - managed care company. The CEO agreed that there

8500is no access problem for Medicaid or charity patients justi fying

8511a new hospital.

851495 . It was argued that KRMC is crowded, and the DMC

8526hospital would help ÐdecompressÑ KRMC, but the evidence showed

8535that KRMC has a number of licensed beds that are not being used

8548for inpatients. In addition, its ED has never gone on

8558diversion, and no patient has ever been turned away due to the

8570lack of a bed. Moreover, the census at KRMC has been declining.

8582It had 25,324 inpatient admissions in 2015, 24,649 admissio ns in

85952016, and 23,301 in 2017.

860196 . The most recent data available at the time of hearing

8613reflected that KRMC has been ru nning at a little less than

862575% occupancy, before its planned bed additions. KRMC is

8634between an eight to 10 minute drive from Doral, and currently

8645has the largest market share within the applicantsÓ d efined

8655service areas. KRMC is readily available and accessible to the

8665residents of Doral.

866897 . KRMC currently has a $90 million dollar expansion

8678project under way. It involves adding beds and two new floors

8689to the West Tower -- a new fifth floor which will add 24 ICU beds

8704and 24 step - down beds, and a new sixth floor which will house

8718the relocated pediatric unit and 12 new medical - surgical beds.

8729KRMC is also adding a new nine - story, 765 parking space garage

8742and other ancillary space. This expansion will re duce the

8752occupancy rate of KRMCÓs inpatient units, and in particular its

8762ICUs. These bed additions, in conjunction with increasing

8770emphasis on outpatient services and the resultant declining

8778inpatient admissions , will alleviate any historical capacity

8785constraints KRMC may have had.

879098 . There are also a number of ways KRMC could be further

8803expanded in the future if needed. The West Tower is designed so

8815it could accommodate a seventh floor, and the East Tower is also

8827designed so that an additional floor co uld also be added to it.

8840In addition, KRMC recently completed construction of a new OR

8850area that is built on pillars. The new construction includes a

8861third floor of shelled - in space that cou ld house an additional

887412 acute care beds. Moreover, this new O R tower was designed to

8887go up an additional two to three floors beyond the existing

8898shelled - in third floor.

890399 . It is clear that KRMC has implemented reasonable

8913strategies for addressing any bed capacity issues it may have

8923experienced in the past. Decomp ression of KRMC is not a reason

8935to approve DMC.

8938Palmetto General Hospital

8941100 . Evidence regarding PGH was provided by its CEO Ana

8952Mederos. Ms. Mederos is a registered nurse and has lived in

8963Miami - Dade Co unty for many years. She has a master of business

8977education from Nova University and has worked in several

8986different hospitals in the c ounty. Specifically, she was the

8996chief operating o fficer ( COO ) at Cedars Medical Center, the CEO

9009at North Shore Medical Center, the CEO at Hialeah Hospital, and

9020has been the CEO at PGH since August of 2006.

9030101 . Ms. Mederos is one of the few witnesses that actually

9042lives in Doral. She travels in and out of the area on a daily

9056basis. Her average commute is only about 15 minutes , and she

9067has multiple convenient options in and out of Doral.

9076102 . PGH is located just off the Palmetto Expressway at

908768th Street. It opened in the early 1970s and has 368 licensed

9099beds , including 52 ICU beds. T he hospital employs about

91091,800 people and has over 600 physicians on its medical staff.

9121103 . PGHÓs occupancy has declined from 79.8% in 2015 to

913264% in 2016 , and even further to 56.7% in 2017. There are many

9145reasons for this decline, including pressure from managed care

9154organizations, the continued increase in the use of outpatient

9163pr ocedures, improvements in technology, and increased

9170competition in the Miami - Dade County market. Ms. Mederos

9180expects that inpatient demand will continue to decline into the

9190foreseeable future.

9192104 . PGH recently activated 31 observation beds to help

9202improve throughput and better accommodate the increasing number

9210of observation patients.

9213105 . PGH offers high - quality care and uses various metrics

9225and indicators to measure and monitor what is going on in the

9237hospital. The hospital has also been recognized w ith numerous

9247awards.

9248106 . Through its parent, Tenet, PGH has contracts with

9258just about every insurance and managed care company that serves

9268the community. The hospital treats Medicaid and indigent

9276patients. PGHÓs Medicaid rate of $3,580 per patient is

9286significantly lower than the rate paid to JMH. PGH has an

9297office dedicated to helping patients get qualified for Medicaid

9306or other financial resources, which not only helps the hospital

9316get paid for its services, it also assists patients and families

9327to ma ke sure that they have benefits on an ongoing basis.

9339Roughly 9 - 10% of PGHÓs patients annually are completely

9349unfunded.

9350107 . PGH only transfers patients if there is a need for a

9363service not provided at the hospital, or upon the patientÓs

9373request. PGH d oes not transfer patients just because they

9383cannot pay. PGH pays physicians to take call s in the ED which

9396also obligates those physicians to provide care to patients that

9406are seen at the hospital.

9411108 . PGH is a for - profit hospital that pays income taxes

9424and property taxes, and does not receive any taxpayer subsidie s

9435like those received by JHS .

9441109 . Ms. Mederos reviewed the applications of JW and DMC,

9452and articulated a number of reasons why, in her opinion, neither

9463application should be approved. She see s no delays in providing

9474care to anyone in the area, as there are hospitals serving Doral

9486in every direction. There are a multitude of FSEDs available

9496and additional FSEDs are being built in Doral by both

9506applicants. There is another FSED being built clo se to PGH by

9518Mount Sinai Medical Center. NCH has also opened a n FSED that

9530has negatively affected the volume of pediatric patients seen at

9540PGH. There are also multiple u rgent care centers. It was

9551Ms. Mederos Ó firm belief that persons living in Doral hav e

9563reasonable geographic access to both inpatient and outpatient

9571medical services. Ms. MederosÓ testimony in this regard is

9580credited.

95811 10 . There are no programs or services being proposed by

9593either applicant that are not already available in the area.

9603Ms. Mederos also noted that there is currently no problem with

9614access to OB services in the area. However, she has a

9625particular concern in that both applicants propose to offer OB

9635services, but neither is proposing to offer NICU services. The

9645evidence show ed that most all of the hospitals that provide OB

9657services to the Doral area offer at least Level II and some

9669Level III NICU services. Thus, in terms of OB care, both

9680proposed hospitals would be a step below what has developed as

9691the standard of care for OB patients in the county.

970111 1 . Ms. Mederos acknowledged that PGH does not have a

9713huge market share in the zip codes that the applicants are

9724proposing to serve, but that does not mean that the impact from

9736either would not be real and significant. If a ho spital is

9748built by either applicant, it will need physicians, with some

9758specialists in short supply. There are tremendous shortages in

9767certain medical fields , such as orthopedics and neurology. In

9776addition, there will be additional competition for nurses and

9785other staff , which will increase the cost of healthcare .

9795112 . The loss of $1.3 to $2 million in contribution

9806margin , as projected by TenetÓs healthcare planner , is a

9815negative impact on PGH as hospital margins become thinner, and

9825those numbers do not include costs like those needed to recruit

9836and retain staff. PGH is again experiencing a nursing shortage,

9846and losing nurses, incurring the higher cost for contract labor,

9856paying overtime, and essentially not having the staff to provide

9866the required servi ces is a serious potential adverse impact from

9877either proposed new hospital. JHS also tends to provide more

9887lucrative benefits than PGH, and a nearby JW hospital is a

9898threat in that regard.

990211 3 . As a final note, Ms. Mederos stated that her

9914conviction tha t there is no need for either proposed hospital in

9926Doral is even more resolute than when she testified in the Batch

9938One Case. With continued declines in admissions, length of stay

9948and patient days, the development of more services for the

9958residents of Dor al, the shortages of doctors and nurses, the

9969ever increasing role of managed care that depresses the demand

9979for inpatient hospital services and other factors, she

9987persuasively explained why no new hospitals are needed in the

9997Doral area.

9999Coral Gables Hospit al (CGH)

1000411 4 . Maria Cristina Jimenez testified on behalf of CGH,

10015where she has worked in a variety of different capacities since

100261985. She was promoted to CEO in March 2017. She has lived in

10039Miami her entire life.

1004311 5 . Ms. Jimenez has been involved in initiatives to make

10055her hospital more efficient. She is supportive of efforts to

10065reduce inpatient hospitalizations and length of stay , as this is

10075what is best for patients. Overall, the hospital length of stay

10086is dropping, which adds to the decreasing de mand for inpatient

10097services.

1009811 6 . CGH is accredited by the Joint Commission, has

10109received multiple awards, and provides high - quality care to its

10120patients. It also has contracts with a broad array of managed

10131care companies as do the other Tenet hospitals.

1013911 7 . CGH treats Medicaid patients, and its total Medicaid

10150rate is less than $3,500 per inpatient. The hospital has a

10162program similar to PGH to help patients get qualified for

10172Medicaid and other resources.

1017611 8 . CGH also provides services to indigent pa tients, and

10188self - pay/charity is about 6% of the hospitalÓs total admissions.

10199The hospital does not transfer patients just because they are

10209indigent. Physicians are compensated to provide care in the

10218emergency room and are expected to continue with that c are if

10230the patients are admitted to the hospital, even if they do not

10242have financial resources. CGH also pays income and property

10251taxes , but does not receive any taxpayer support.

1025911 9 . CGH generally serves the Little Havana, Flagami,

10269Miami , and Coral Gab les communities, and its service area

10279overlaps with those of the applicants.

102851 20 . In order to better serve its patients and to help it

10299compete in the highly competitive Miami - Dade County marketplace,

10309CGH is developing a freestanding ED at the corner of Bi rd Road

10322and Southwest 87th Avenue, which is scheduled to open in January

103332020. This will provide another resource for patients in the

10343proposed service areas.

1034612 1 . Ms. Jimenez had reviewed the CON applications at

10357issue in this case. She does not believe that either hospital

10368should be approved because it will drain resources from CGH, not

10379only from a financial standpoint, but also physician and nurse

10389staffing. CGH experiences physician shortages. Urologists are

10396in short supply, as are gastrointestinal ph ysicians that perform

10406certain procedures. Hematology, oncology , and endocrinology are

10413also specialty areas with shortages. The addition of another

10422hospital will exacerbate those shortages at CGH.

1042912 2 . While CGH does not have a large market share in the

10443proposed PSA of either applicant, anticipated impact from

10451approval of either is real and substantial. A contribution

10460margin loss of $1.2 to $2.2 million per year, as projected by

10472TenetÓs healthcare planner, would be significant. The drain on

10481resources, including staff and physicians, is also of

10489significant concern.

10491Hialeah Hospital

1049312 3 . Dr. Jorge Perez testi fied on behalf of Hialeah.

10505Dr. Perez is a pathologist and medical director of laboratory at

10516the hospital. More significantly, Dr. Perez has been on the

10526hospitalÓs staff since 2001 and has served in multiple

10535leadership roles , including c hair of the Performance Improvement

10544Council, chief of s taff ; and since 2015, c hair of the Hialeah

10557Hospital Governing Board.

1056012 4 . Hialeah offers obstetrics services an d a Level II

10572NICU with 12 beds. Approximately 1,400 babies a year are born

10584there.

1058512 5 . Hialeah Ós occupancy has been essentially flat for the

10597past three years, at below 40%, and it clearly has ample excess

10609capacity. On an average day, over 200 of Hialeah Ós beds are

10621unoccupied. Like other hospitals in the c ounty, Hialeah has a

10632number of competitors. The growth of managed care has affected

10642the demand for inpatient beds and services at Hialeah.

1065112 6 . Hialeah treats Medicaid and indigent patients.

10660Approximately 15% of HialeahÓs admissions are unfunded.

1066712 7 . As with its sister Tenet hospitals, Hialeah is a for -

10681profit hospital that pays taxes and does not receive tax dollars

10692for providing care to the indigent.

1069812 8 . Dr. Perez succinctly and persuasively iden tified a

10709variety of reasons why no new hospital is needed in Doral.

10720First and foremost, there is plenty of capacity at the existing

10731hospitals in the area, including Hialeah. Second, both

10739inpatient admissions and length of stay continue trending

10747downward. Care continues to shift toward outpatient services,

10755thereby reducing the demand for inpatient care.

1076212 9 . According to Dr. Perez, if a new hospital is approved

10775in Doral it will bring with it adverse impacts on existing

10786hospitals, including Hialeah. A ne w hospital in Doral will

10796attract patients, some of which would have otherwise gone to

10806Hialeah. Moreover, Doral has more insured patients, meaning the

10815patients that would be lost would be good payors. There would

10826also be a significant risk of loss of staf f to a new hospital.

10840Dr. PerezÓs testimony in this regard is credible.

10848IV. Statutory and Rule Review Criteria

108541 30 . In 2008, the Florida Legislature streamlined the

10864review criteria applicable for evaluating new hospital

10871applications. Mem Ó l Healthcare Gr p. v. AHCA , Case No. 12 -

108840429CON, RO at 32 ( Fla. DOAH Dec. 7, 2012). The criteria

10896specifically eliminated included quality of care, availability

10903of resources, financial feasibility, and the costs and methods

10912of proposed construction. Lee Mem Ó l Health Syst em v. AHCA , Case

10925No. 13 - 2508CON, RO at 135 ( Fla. DOAH Mar. 28, 2014). The

10939remaining criteria applicable to new hospital projects are set

10948forth at section 408.035(1), Florida Statutes.

10954Section 408.035(1)(a): The need for the healthcare

10961facilities and heal th services being proposed.

1096813 1 . Generally, CON applicants are responsible for

10977demonstrating need for new acute care hospitals, typically in

10986the context of a numeric need methodology adopted by AHCA.

10996However, AHCA has not promulgated a numeric need met hodology to

11007calculate need for new hospital facilities. Florida

11014Administrative Code R ule 59C - 1.008(2)(e) provides that if no

11025agency need methodology exists, the applicant is responsible for

11034demonstrating need through a needs assessment methodology , which

11042must include, at a minimum, consideration of the following

11051topics, except where they are inconsistent with the applicable

11060statutory and rule criteria:

11064(a) Population demographics and dynamics;

11069(b) Availability, utilization and quality

11074of like services i n the district,

11081subdistrict, or both;

11084(c) Medical treatment trends; and

11089(d) Market conditions .

1109313 2 . Both applicants propose to build small community

11103hospitals providing basic acute care and OB services in the

11113Doral area of western Miami - Dade County. Both applicants point

11124to the increasing population and the lack of an acute care

11135hospital in Doral as evidence of need for a hospital. The DMC

11147application focuses largely on geographic access concerns, while

11155the JW application is premised upon six argum ents as to why JHS

11168contends its proposed JW hospital should be approved.

1117613 3 . The lack of a hospital in Doral is not itself an

11190indication of need. 3/ In addition, population growth, and the

11200demands of the population for inpatient hospital beds, cannot be

11210considered in a vacuum. Sound healthcare planning requires an

11219analysis of existing area hospitals, including the services they

11228offer and their respective locations; how area residents travel

11237to existing hospitals, and any barriers to access; the

11246utilizati on of existing hospitals and amount of capacity they

11256have; and other factors which may be relevant in a given case.

1126813 4 . Doral is in the west/northwest part of Miami - Dade

11281County, in between the Miami International Airport (to the east)

11291and the Everglades (to the west). It is surrounded by major

11302roadways, with US Highway 27/Okeechobee Road running diagonally

11310to the north, US Highway 836/Dolphin Expressway running along

11319its southern edge, US Highway 826/Palmetto Expressway running

11327north - south to the east, a nd the Florida Turnpike running north -

11341south along the western edge of Doral. To the west of the

11353Turnpike is the Everglades, where there is minimal population

11362and very limited development possible in the future.

1137013 5 . The City of Doral itself has an area o f about 15

11385square miles, and is only two or three times the size of the

11398Miami International Airport, which sits just east of Doral.

11407Much of Doral is commercial and industrial, with the largest

11417concentration of residential areas being in the northwest part

11426of the city.

1142913 6 . While there is unquestionably residential growth in

11439Doral, the population of Doral is currently only about

1144859,000 people. Doral is not as densely populated as many areas

11460of Miami - Dade County, has a number of golf course communities,

11472and is generally a more affluent area with a higher average

11483household income than much of Miami - Dade County.

1149213 7 . JW proposes to locate its hospital on the eastern

11504side of Doral, just west of Miami International Airport, while

11514the DMC site is on the west ern side of Doral, just east of the

11529Everglades. JWÓs site is located in an industrial area with few

11540residents, while the DMC site is located in an area where future

11552growth is likely to be limited. Both sites have downsides for

11563development of a hospital, with both applicants spending

11571considerable time at hearing pointing out the flaws of each

11581otherÓs chosen location.

1158413 8 . Both applicants define their service areas to include

11595the City of Doral, but also areas outside of Doral. Notably,

11606the entire DMC serv ice area is contained within KRMCÓs existing

11617service area, with the exception of one small area. While the

11628population of Doral itself is only 59,000 people, there are more

11640concentrated populations in areas outside of Doral (except to

11649the west). However, the people in these areas are closer to

11660existing hospitals like PGH, Hialeah, KRMC, and others.

1166813 9 . For the population inside Doral, there are several

11679major roadways in and out of Doral, and area residents can

11690access several existing hospitals with plent y of capacity within

11700a 20 - minute drive time, many closer than that.

117101 40 . It was undisputed that inpatient acute care hospital

11721use rates continue to decline. There are different reasons for

11731this, but it was uniformly recognized that decreasing inpatient

11740u se rates, and a shift toward outpatient services, are ongoing

11751trends in the market. These trends existed at the time of the

11763Batch One Case. As observed by TenetÓs healthcare planner at

11773hearing: ÐThe occupancy is lower today than it was two years

11784ago, th e use rates are lower, and the actual utilization is

11796lower.Ñ

1179714 1 . Both applicants failed to establish a compelling case

11808of need. While there is growth in the Doral area, it remains a

11821relatively small population, and there was no evidence of

11830community ne eds being unmet. Sound healthcare planning, and the

11840statutory criteria, require consideration of existing hospitals,

11847their availability, accessibility, and extent of utilization.

11854These considerations weigh heavily against approval of either

11862CON applicati on, even more so than in the prior case.

11873Section 408.035(1)(b): The availability, accessibility,

11878and extent of utilization of existing healthcare facilities

11886and health services in the service district of the

11895applicant ; and Section 408.035(1)(e): The exte nt to which

11904the proposed services will enhance access to healthcare for

11913residents of the service district.

1191814 2 . As stated above, there are several existing hospitals

11929in close proximity to Doral. Thus, the question is whether they

11940are accessible and have capacity to serve the needs of patients

11951from the Doral area. The evidence overwhelmingly answers these

11960questions in the affirmative.

1196414 3 . Geographic access was a focal point of the DMC

11976application, which argued that there are various barriers to

11985access in and around Doral, such as a canal that runs parallel

11997to US Highway 27/Okeechobee Road, train tracks and a rail yard,

12008industrial plants, and the airport. While the presence of these

12018things is undeniable, as is the fact that there is traffic in

12030Miami, based upon the evidence presented, they do not present

12040the barriers that DMC alleges. Rather, the evidence was

12049undisputed that numerous hos pitals are accessible within

1205720 minutes of the proposed hospital sites, and some within 10 to

1206915 minutes. All of Dora l is within 30 minutes of multiple

12081hospitals. These are reasonable travel times and are not

12090indicative of a geographic access problem, regardless of any

12099alleged Ðbarriers.Ñ

1210114 4 . In addition, existing hospitals clearly have the

12111capacity to serve the Doral community, and they are doing so.

12122Without question, there is excess capacity in the Miami - Dade

12133County market. With approximately 7 , 500 hospital beds in the

12143county running at an average occupancy just over 50%, there are

12154around 3 , 500 beds available at an y given time. Focusing on the

12167hospitals closest to Doral (those accessible within 20 minutes),

12176there are hundreds of beds that are available and accessible

12186from the proposed service areas of the applicants. KRMC is

12196particularly noteworthy because of its proximity to, and market

12205share in, the Doral area. The most recent utilization and

12215occupancy data for KRMC indicate that it has, on average, 100

12226vacant beds. This is more than the entire 80 - bed hospital

12238proposed in the DMC application (for a service area that is

12249already served and subsumed by KRMC). Moreover, KRMC is

12258expanding , and will soon have even more capacity at its location

12269less than a 10 - minute drive from the DMC site.

1228014 5 . From a programmatic standpoint, neither applicant is

12290proposing any progr ams or services that are not already

12300available at numerous existing hospitals, and , in fact, both

12309would offer fewer programs and services than other area

12318hospitals. As such, patients in need of tertiary or specialized

12328services will still have to travel to other hospitals like PGH,

12339KRMC, or JMH. Alternatively, if they present to a small

12349hospital in Doral in need of specialized services, they will

12359then have to be transferred to an appropriate hospital that can

12370treat them. The same would be true for babies born at either

12382DMC or JW in need of a NICU.

1239014 6 . Similarly, there are bypass protocols for EMS to take

12402cardiac, stroke, and trauma patients to the closest hospital

12411equipped to treat them, even if it means bypassing other

12421hospitals not so equipped, like JW and DMC. Less acute patients

12432can be transported to the closest ED. And since both applicants

12443are building FSEDs in Doral, there will be ample access to

12454emergency services for residents of Doral.

1246014 7 . This criterion does not weigh in favor of approval of

12473either hospital. To the contrary, the evidence overwhelmingly

12481established that existing hospitals are available and accessible

12489to Doral area residents.

12493Section 408.035(1)(e), (g) and (i): The extent to which

12502the proposed services will enhance access t o healthcare ,

12511the extent to which the proposal will foster competition

12520that promotes quality and cost - effectiveness, and the

12529applicantÓs past and proposed provision of healthcare

12536services to Medicaid patients and the medically indigent.

1254414 8 . It goes with out saying that any new hospital is going

12558to enhance access to the people closest to its location; but as

12570explained above, there is no evidence of an access problem, or

12581any pressing need for enhanced access to acute care hospital

12591services. Rather, the evi dence showed that Doral area residents

12601are within very reasonable travel times to existing hospitals,

12610most of which have far more extensive programs and services than

12621either applicant is proposing to offer. Indeed, the proposed

12630DMC service area is contain ed within KRMCÓs existing service

12640area, and KRMC is only 10 minutes from the DMC site.

1265114 9 . Neither applicant would enhance access to tertiary or

12662specialized services, and patients in need of those services

12671will still have to travel to other hospitals, or worse, be

12682transferred after presenting to a Doral hospital with more

12691limited programs and services.

126951 50 . Although it was not shown to be an issue, access to

12709emergency services is going to be enhanced by the FSEDs being

12720built by both applicants. Thus, to the extent that a new

12731hospital would enhance access, it would be only for non - emergent

12743patients in need of basic, non - tertiary level care. Existing

12754hospitals are available and easily accessible to these patients.

12763In addition, healthy competition exists between several existing

12771providers serving the Doral area market. That healthy

12779competition would be substantially eroded by approval of the DMC

12789application, as HCA would likely capture a dominant share of the

12800market.

1280115 1 . While approval of the JW applica tion might not create

12814a dominant market share for one provider, it would certainly not

12825promote cost - effectiveness given the fact that it costs the

12836system more for the same patient to receive services at a JHS

12848hospital than other facilities. Indeed, approv al of JWÓs

12857application would mean that the JW campus will have the more

12868expensive hospital - based billing rates.

1287415 2 . Florida Medicaid diagnosis related group (DRG)

12883payment comparisons among hospitals are relevant because both

12891DMC and JW propose that at le ast 22% of their patients will be

12905Medicaid patients. Data from the 2017 - 18 DRG calculator

12915provided by the Medicaid program office was used to compare JHS

12926to the three Tenet hospitals, KRMC, and Aventura Hospital,

12935another EFD hospital in Miami - Dade County. The data shows that

12947JHS receives the highest Medicaid rate enhancement per discharge

12956for the same Medicaid patients ($2,820.06) among these six

12966hospitals in the county. KRMC r eceives a modest enhancement

12976of $147.27.

1297815 3 . Comparison of Medicaid Managed Care Reimbursement

12987over the period of fiscal years 2014 - 2016 show that JHS receives

13000substantially more Medicaid reimbursement per adjusted patient

13007day than any of the hospitals in this proceeding, with the other

13019hospitals receiving between one - third and on e - half of JHS

13032reimbursement. In contrast, among all of these hospitals , KRMC

13041had the lowest rate for each of the three years covered by the

13054data, which means KRMC (and by extension DMC) would cost the

13065Medicaid program substantially less money for care of Medicaid

13074patients.

1307515 4 . Under the new prospective payment system instituted

13085by the S tate of Florida for Medicaid reimbursement of acute care

13097hospital providers, for service between July 1, 2018 , and

13106March 31, 2019, JHS is the beneficiary of an automatic r ate

13118enhancement of more than $8 million. In contrast, KRMCÓs rate

13128enhancement is only between $16,000 and $17,000. Thus, it will

13140cost the Medicaid program substantially more to treat a patient

13150using the same services at JW than at DMC. Furthermore, rath er

13162than enhance the financial viability of the JHS system, the

13172evidence indicates that the JW proposal will be a financial

13182drain on the JHS system.

1318715 5 . Finally, JHSÓs past and proposed provision of care to

13199Medicaid and indigent patients is noteworthy, bu t not a reason

13210to approve its proposed hospital. JW is proposing this hospital

13220to penetrate a more affluent market, not an indigent or

13230underserved area, and it proposes to provide Medicaid and

13239indigent care at a level that is consistent with the existing

13250hospitals.

1325115 6 . JHS also receives the highest Low Income Pool (LIP)

13263payments per charity care of any system in the state, and is one

13276of only a handful of hospital systems that made money afte r

13288receipt of the LIP payments. HCA - affiliated hospitals, by

13298com parison, incur the second greatest cost in the state for

13309charity care taking LIP payments into consideration.

1331615 7 . Analysis of standardized net revenues per adjusted

13326admission (NRAA) among Miami - Dade County acute care hospitals, a

13337group of 16 hospitals, s hows JHS to be either the second or the

13351third highest hospital in terms of NRAA. KRMC, in contrast,

13361part of the EFD/HCA hospitals, is about 3 % below the average of

13374the 16 hospitals for NRAA.

1337915 8 . DMCÓs analysis of standardized NRAA using data from

133902014, 2015 , and 2016 , among acute care hospitals receiving local

13400government tax revenues , shows JHS receives more net revenue

13409than any of the other hospitals in this grouping.

1341815 9 . Using data from FY 2014 to F Y 2016, DMC compared

13432hospital costs among the four existing providers that are

13441parties to this proceeding and JMH as a representative of JHS.

13452Standardizing for case mix, fiscal year end, and location, an

13462analysis of costs per adjusted admission shows that the

13471hospitals other than JMH have an average cost of between a half

13483and a third of JMHÓs average cost. The same type of analysis of

13496costs among a peer group of eight statutory teaching hospitals

13506shows JHSÓs costs to be the highest.

135131 60 . It should also be noted that if JW were to fail or

13528experience significant losses from operations, the taxpayers of

13536Miami - Dade County will be at risk. In contrast, if DMC were to

13550fail financially, EFD/HCA will shoulder the losses.

1355716 1 . When the two applications are evaluated in the

13568context of the above criteria, the gr eater weight of the

13579evidence does not mitigate in favor of approval of either.

13589However, should AHCA decide to approve one of the applicants in

13600its final order, preference should be given to DMC because of

13611its lower costs per admission for all categories o f payors, and

13623in particular, the lower cost to the Florida Medicaid Program.

13633In addition, the risk of financial failure would fall upon

13643EFD/HCA, rather than the taxpayers of Miami - Dade County.

13653Rule 59C - 1.008(2)(e): Need considerations.

1365916 2 . Many of the considerations enumerated in r ule 59C -

136721.008(2)(e) overlap with the statutory criteria, but there are

13681certain notable trends and market conditions that warrant

13689mention. Specifically, while the population of Doral is

13697growing, it remains relatively smal l, and does not itself

13707justify a new hospital. And while there are some more densely

13718populated areas outside of the city of Doral, they are much

13729closer to existing hospitals having robust services and excess

13738capacity.

1373916 3 . Doral is a more affluent area, and there was no

13752evidence of any financial or cultural access issues supporting

13761approval of either CON application.

1376616 4 . The availability, utilization , and quality of

13775existing hospitals are clearly not issues, as there are several

13785existing hospitals with plenty of capacity accessible to Doral

13794area residents.

1379616 5 . In terms of medical treatment trends, it was

13807undisputed that use rates for inpatient hospital services

13815continue trending downward, and that trend is expected to

13824continue. Concomitantly, there is a marked shift toward

13832outpatient services in Miami - Dade County and elsewhere.

1384116 6 . Finally, both applicants are proposing to provide OB

13852services without a NICU, which is below the standard in the

13863market. While not required for the provision of obstetric s,

13873NICU backup is clearly the most desirable and best practice.

1388316 7 . For the foregoing reasons, the considerations in

13893rule 59C - 1.008(2)(e) do not weigh in favor of approval of either

13906hospital.

13907CONCLUSIONS OF LAW

1391016 8 . The Division of Administrative Heari ngs has

13920jurisdiction over the subject matter of and the parties to this

13931proceeding. §§ 120.569, 120.57(1), and 408.039(5), Fla. Stat.

1393916 9 . In order for an existing healthcare facility to have

13951standing to intervene in a CON proceeding, it must show that i t

13964will be Ðsubstantially affectedÑ by approval of the CON

13973application at issue. § 408.039(5), Fla. Stat.

139801 70 . JW and DMC , as applicants , have party status and,

13992therefore, appropriate standing in this matter. §§ 120.52(13)

14000and 408.039(5), Fla. Stat. The others have standing to

14009participate as existing providers who allege the addition of a

14019new hospital in Miami - Dade County will have a substantial and

14031adverse impact on their operations.

1403617 1 . Specifically, the Tenet H ospitals proved by a

14047preponderance of t he evidence that they have standing to

14057participate as a party in this proceeding. The three hospitals

14067are in the same district, and are proximate to the proposed

14078hospital sites. Direct annual contribution margin losses per

14086hospital were reasonably projec ted in the range of over

14096$1. 1 million to almost $2.9 million. This does not include the

14108loss of tertiary referrals, which is particularly an issue for

14118PGH as a tertiary hospital.

1412317 2 . There was also significant and persuasive evidence

14133regarding the impac t of a new hospital on staffing. A hospital

14145requires physicians and nursing staff regardless of volume, and

14154this staff will likely be recruited from other providers. This

14164drives up the cost of healthcare .

1417117 3 . While none of this adverse impact will impe ril the

14184Tenet H ospitals, it is certainly substantial enough to establish

14194standing for PGH, Hialeah , and CGH. It should be noted,

14204however, that had the applicants established need for their

14213proposed hospitals, which they did not, this adverse impact

14222would not have been significant enough to warrant deni al of the

14234applications.

1423517 4 . The parties stipulated that section 408.035(2)

14244establishes the statutory review criteria applicable to general

14252hospital applications. The review criteria are set forth in

14261sectio n 408.035(1).

1426417 5 . The award of a CON must be based on a balanced

14278consideration of all applicable statutory and rule criteria.

14286Balsam v. DepÓt of HRS , 486 So. 2d 1341 (Fla. 1st DCA 1986).

14299The appropriate weight to be given to each criterion is not

14310fixed , but rather varies based upon the facts of the case. See,

14322e.g. , Morton F. Plant Hosp. AssÓn, Inc. v. DepÓt of H RS , 491 So.

143362d 586, 589 (Fla. 1st DCA 1986) (quoting North Ridge Gen. Hosp.,

14348Inc. v. NME Hosps., Inc. , 478 So. 2d 1138, 1139 (Fla. 1st DCA

143611985 )); Collier Med. Ctr., Inc. v. DepÓt of H RS , 462 So. 2d 83,

1437684 (Fla. 1st DCA 1986).

1438117 6 . A CON applicant bears the burden to prove by a

14394preponderance of the evidence that its CON application should be

14404approved. See, e.g. , Boca Raton Artificial Kidney Ctr ., Inc. v.

14415DepÓt of H RS , 475 So. 2d 260, 263 (Fla. 1st DCA 1985);

14428§ 120.57(1)(j), Fla. Stat.

1443217 7 . An administrative hearing involving disputed issues

14441of material fact is a de novo proceeding in which the ALJ

14453independently evaluates the evidence presented . Fla. DepÓt of

14462Transp. v. J.W.C. Co. , 396 So. 2d 778, 787 (Fla. 1st DCA 1981);

14475§ 120.57(1) (k) , Fla. Stat. AHCAÓs preliminary decision with

14484regard to JW and DMCÓs CON applications and its findings in the

14496SAARs are not entitled to a presumption of correct ness. Id .

1450817 8 . As stipulated to by the parties, the CON applications

14520at issue in this case are Ðvirtually the same applicationsÑ that

14531were filed in the Batch One Case. It is a Ðcore principle of

14544our justice systemÑ that like cases should be treated alik e.

14555Gessler v. Dep Ó t of Bus . and Prof Ó l Reg . , 627 So. 2d 501 (Fla.

145744th DCA 1993), superseded on other grounds , Caserta v. Dep Ó t of

14587Bus . and Prof Ól Reg . , 686 So. 2d 651 (Fla. 5th DCA 1996). This

14603core principle applies to decisions issued by state agencies.

14612Id. at 503.

1461517 9 . Being mindful of the CourtÓs holding in J.W.C. as to

14628the de novo nature of this proceeding, it is also true that

14640inconsistent orders based on similar facts, without rational

14648explanation, violates principles of fundamental fairness. Id.

14655at 504. Accordingly, Ð[a]n agency generally must follow its own

14665precedents.Ñ Flagship Manor, LLC v. Fla. Hous. Fin. Corp. , 199

14675So. 3d 1090, 1094 (Fla. 1 st DCA 2016) (citing Bethesda

14686Healthcare Sys., Inc. v. Ag . for Healthcare Admin. , 945 So. 2d

14698574, 576 (Fla. 4th DCA 2006)); see also Nordheim v. DepÓt of

14710Envtl. Prot. , 719 So. 2d 1212, 1214 (Fla. 3d DCA 1998), affÓd

14722sub nom. Nordheim v. Fla. Fish & Wildlife Conser . CommÓn , 785

14734So. 2d 523 (Fla. 3d DCA 2000) (holding it was error for agency

14747to fail to consi der its own prior precedent).

147561 80 . In the context of successive CON applications, an

14767application for a previously denied project is not subject to

14777traditional notions of res judicata , but in order to reach a

14788different result (approval), it is incumbent up on the applicant

14798to come forward with Ðnew facts, changed conditions, or

14807additional submissions.Ñ Delray Med . Ctr . , Inc. v. AHCA , 5 So.

148193d 26, 30 (Fla. 4th DCA 2009) (quoting Thomson v. Dept. of

14831Envtl . Reg . , 511 So. 2d 989, 991 - 92 (Fla. 1987)). A differe nt

14847result on the same application must be based upon Ðsubstantial

14857changes in material circumstances between the two applications.Ñ

14865Delray , 5 So. 3d at 30.

14871Balancing the Applicable Statutory and Rule Criter i a

1488018 1 . AHCA is tasked with utilizing the statuto ry review

14892criteria in section 408.035 in evaluating each hospitalÓs

14900proposed project. The 2008 amendments to the CON law

14909significantly modified the application and review process for

14917CON applications for general hospitals, including the criteria

14925considere d. Certain previously applicable review criteria were

14933eliminated, but significantly, "need" (as codified at section

14941408.035(1)(a) and (b)) was not altered, and remains the focus of

14952the CON law.

1495518 2 . Section 408.035(2) specifically outlines the CON

14964review criteria set forth in section 408.035(1) that are

14973applicable to general hospital applications, which include the

14981following:

14982(a) The need for the healthcare facilities

14989and health services being proposed.

14994(b) The availability, accessibility, and

14999extent o f utilization of existing healthcare

15006facilities and health services in the

15012service district of the applicant.

15017* * *

15020(e) The extent to whic h the proposed

15028services wil l enhance access to healthcare

15035for residents of the service district.

15041* * *

15044(g) The ex tent to which the proposal will

15053foster competition that promotes quality and

15059cost - effectiveness.

15062* * *

15065(i) The applicantÓs past and proposed

15071provision of healthcare services to Medicaid

15077patients and the medically indigent.

15082§ 408.035(1), Fla. Stat.

1508618 3 . In addition, since AHCA no longer issues a fixed need

15099pool for acute care beds, the applicants are bound to follow

15110r ule 59C - 1.008(2)(e)2., which states that:

15118[T]he applicant will be responsible for

15124demonstrating need through a needs

15129assessment methodology which must include,

15134at a minimum, consideration of the following

15141topics . . . .

15146a. Population demographics and dynamics;

15151b. Availability, utilization and quality of

15157like services in the district, subdistrict

15163or both;

15165c. Medical treatment trends; and,

15170d. Market conditions.

1517318 4 . When considered in light of the above four factors,

15185neither applicant demonstrated need for its proposed hospital.

15193Specifically, neither applicant established the existence of

15200typical indicators of "need," such as progr ammatic, financial,

15209or geographic access barriers to the types of hospital services

15219proposed.

1522018 5 . The evidence clearly established that existing

15229hospitals have available capacity, and on any given day have

15239more than adequate available beds to serve the c urrent

15249population and the projected population growth.

1525518 6 . AHCA does not have a travel - time standard rule with

15269respect to access to acute care services. See , Mem Ó l Healthcare

15281Group, Inc. , d/b/a Mem Ó l Hosp . Jacksonville v. Ag . for

15294Healthcare Admin . and S hands Jacksonville Med . Ctr . , Inc. , DOAH

15307Case No. 12 - 0429CON , FO at 141 ( Fla. DOAH Dec. 7, 2012; Fla.

15322AHCA Apr. 10, 2013 ) (hereafter Memorial ) ( citing Wellington Reg.

15334Med. Ctr., Inc., d/b/a Wellington Reg Ól Med. Ctr. v. Ag. for

15346Healthcare Admin. , Case Nos. 05 - 2352CON, 05 - 2594CON, and 05 -

153592753CON , FO at 110 and 354 - 58 (Fla. DOAH Apr. 5, 2007; Fla. AHCA

15374Aug. 9, 2007, FO at 27, 34 - 35), aff'd, 5 So. 3d 26 (Fla. 4th DCA

153912009).

1539218 7 . It was concluded in the Memorial decision that Ð20 to

1540530 minutes is a reasonable travel time standard for accessing

15415general acute care hospital services, with 30 minutes being the

15425outside range.Ñ Memorial , FO at 142. Multiple health planning

15434and hospital operational witnesses that testified in this case

15443agreed.

1544418 8 . Approval of ei ther application would not materially

15455improve geographic access to hospital services for most Doral

15464area residents. Rather, the evidence established that area

15472residents are within reasonable drive times to multiple existing

15481hospitals.

1548218 9 . The evidence a lso established that approval of the

15494DMC hospital is not needed to decompress KRMC.

155021 90 . Competition for doctors, nurses , and other hospital

15512personnel is already intense and problematic due to shortages of

15522nurses and some physician specialties. Approval of either

15530application would exacerbate this competition, potentially

15536driving up costs of providing care.

1554219 1 . As was stated in Memorial :

15551136. It has been stated that "[n]ot every

15559city, town or hamlet can or should have its

15568own hospital." Columbia Hosp. Corp. of

15574South Broward v. Ag. for Healthcare Admin. ,

15581Case Nos. 01 - 2891CON and 01 - 2892CON (Fla.

15591DOAH July 3, 2002, at FOF 62; Fla. AHCA

15600Sept. 30, 2002) (appl ication to establish a

15608new 100 - bed hospital in Broward County),

15616aff'd, 883 So. 2d 283 (Fla. 1st DCA 2004);

15625see also Manatee Memorial Hosp., L.P. v. Ag.

15633for Healthcare Admin. , Case Nos. 04 - 2723CON,

1564104 - 3027CON, and 04 - 3147CON (Fla. DOAH Dec.

156511, 2005, at FOF 104; Fla. AHCA Apr. 11,2006)

15661(application to establish a new acute care

15668hospital in Sarasota County) ("A community's

15675desire for a new hospital does not mean

15683there is a 'need' for a new hospital. Under

15692the CON program, the determination of need

15699for a new hospital must be based upon sound

15708health planning principles, not the desires

15714of a particular local g overnment or its

15722citizens.") (cited in Osceola, LLC, d/b/a

15729St. Cloud Reg'l Med. Ctr. v. Ag. For

15737Healthcare Admin. and Osceola Reg'l Hosp.,

15743Inc., d/b/a Osceola Reg'l Med. Ctr. , Case

15750No. 08 - 0612CON (Fla. DOAH Dec. 31, 2008, at

15760COL 275; Fla. AHCA Mar. 3, 2009 )).

15768137. Just as the desires of local

15775government or citizens may not dictate the

15782approval of a new hospital, neither should

15789the motivations of a particular health

15795system, no matter how noble, trump the

15802statutory requirement that ÐneedÑ for the

15808proposal be demonstrated.

1581119 2 . In its Final Order in the Batch One Case, the Agency

15825discussed the factual circumstances in three cases involving CON

15834applications for new acute care hospitals that were submitted to

15844the Agency after the 2008 changes to the review c riteria in

15856section 408.035. Those cases were Memorial ; Columbia Hospital

15864(Palm Beaches) Limited Partnership , d/b/a West Palm Hospital and

15873Jupiter Medical Center, Inc. , d/b/a Jupiter Medical Center v.

15882Florida Regional Medical Center and Agency for Healthca re

15891Admin. , Case Nos. 12 - 0428CON and 12 - 0496CON ( Fla. DOAH Apr. 30,

159062013; Fla. AHCA Jun e 6, 2013); and Lee Memorial Health System v.

15919Agency for Healthcare Admin. , Case Nos. 13 - 2508CON and 13 -

159312558CON ( Fla. DOAH Mar. 28, 2014; Fla. AHCA Apr. 24, 2014).

1594319 3 . Following its discussion of the three above - cited

15955cases, AHCA concluded:

15958The case at hand is very similar to those of

15968Memorial Hospital Jacksonville, Columbia

15972Hospital and Lee Memorial . The city of

15980Doral has a relatively small population

15986(Recommended Orde r at Paragraph 96). The

15993existing beds in District 11 are

15999underutilized with an overall occupancy rate

16005of roughly 53% ( See Transcript, Volume 23,

16013Page 3660; Tenet Exhibit 5). And, there was

16021no competent, substantial record evidence

16026that the "geographic ba rriers to access"

16033alleged by both JW and DMC prevented

16040residents of the proposed service area from

16047accessing existing providers ( See , e.g.

16053Transcript, Volume 17, Pages 2753 - 2759). In

16061sum, if the Agency were to grant either

16069applicant a CON, it would be dep arting from

16078prior Agency precedent without any rational

16084explanation.

16085( FO at 25)

1608919 4 . JW and DMC, individually and collectively, failed to

16100demonstrate need for either proposed hospital. To the contrary,

16109the evidence demonstrated that neither hospital i s needed.

16118Accordingly, based upon the evidence presented in this case, the

16128CON applications at issue should be denied.

16135195. I t is important to note that these second

16145applications for the same previously denied projects were not

16154supported by Ðnew facts, changed conditions, or additional

16162submissionsÑ. The applicants are identical to the prior

16170applications, and the record in this case does not reflect any

16181Ðsubstantial changes in material circumstances.Ñ Delray , 5 So.

161893d at 30.

1619219 6 . Indeed, a thorough c omparison of the facts in the

16205prior case and this case demonstrates that the only things that

16216have changed (further decline in use rates, more vacant beds,

16226expansion of Kendall) make the case for need less compelling now

16237than in the prior case. Thus, ther e is no basis to reach a

16251different result in this case.

1625619 7 . Should the Agency reject the above recommendation and

16267determine to approve one, but not both, of the applications at

16278issue, preference should be given to the DMC application for the

16289reasons stated in Findings of Fact Nos. 152 through 161 above.

16300RECOMMENDATION

16301Based on the foregoing Findings of Fact and Conclusions of

16311Law, it is RECOMMENDED that the Agency for Healthcare

16320Administration enter a final order denying East Florida - DMC,

16330Inc.Ós CON A pp lication No. 10432 and denying The Public Health

16342Trust of Miami - Dade County, Florida , d/b/a Jackson Hospital

16352WestÓs CON Application No. 10433.

16357DONE AND ENTERED this 30th day of April , 2019 , in

16367Tallahassee, Leon County, Florida.

16371S

16372W. DAVID WATKINS

16375Administrative Law Judge

16378Division of Administrative Hearings

16382The DeSoto Building

163851230 Apalachee Parkway

16388Tallahassee, Florida 32399 - 3060

16393(850) 488 - 9675

16397Fax Filing (850) 921 - 6847

16403www.doah.state.fl.us

16404Filed with the Clerk of the

16410Di vision of Administrative Hearings

16415this 30th day of April , 2019 .

16422ENDNOTE S

164241/ Kendall Healthcare Group, Ltd. v. The Public Health Trust

16434of Miami - Dade County, Florida, d/b/a Jackson Hospital West , Case

16445No. 16 - 0112CON (Fla. DOAH Mar. 16, 2017; Fla. AHCA Apr. 26,

164582018). The Batch One Case Final Order is on appeal at the First

16471DCA. See Case No. 1D18 - 1975.

164782/ The corollary of this statement, as announced at the outset

16489of the hearing, is that none of the Findings of F act made in the

16504Batch One Proceeding are binding upon the undersigned in this

16514proceeding. (Tr . p. 19).

165193/ Doral is one of 34 municipalities in Miami - Dade County,

16531several of which do not have a hospital.

16539COPIES FURNISHED:

16541Stephen A. Ecenia, Esquire

16545Rutledge Ecenia, P.A.

16548Suite 202

16550119 Sou th Monroe Street

16555Tallahassee, Florida 32301

16558(eServed)

16559Kevin Michael Marker, Esquire

16563Agency for Healthcare Administration

16567Mail Stop 7

165702727 Mahan Drive

16573Tallahassee, Florida 32308

16576(eServed)

16577R. David Prescott, Esquire

16581Rutledge, Ecenia, and Purnell, P.A.

1658611 9 South Monroe Street, Suite 202

16593Tallahassee, Florida 32302

16596(eServed)

16597Richard Joseph Saliba, Esquire

16601Agency for Healthcare Administration

16605Fort Knox Building III, Mail Stop 7

166122727 Mahan Drive

16615Tallahassee, Florida 32308

16618(eServed)

16619Michael J. Glazer, Esqu ire

16624Ausley & McMullen

16627123 South Calhoun Street

16631Post Office Box 391

16635Tallahassee, Florida 32302

16638(eServed)

16639Eugene Dylan Rivers, Esquire

16643Ausley & McMullen, P.A.

16647123 South Calhoun Street

16651Tallahassee, Florida 32301

16654(eServed)

16655Thomas Francis Panza, Esquire

16659Pan za, Maurer & Maynard, P.A.

16665Suite 905

166672400 East Commercial Boulevard

16671Fort Lauderdale, Florida 33308

16675(eServed)

16676Elizabeth L. Pedersen, Esquire

16680Panza, Maurer, & Maynard, P.A.

16685Suite 905

166872400 East Commercial Boulevard

16691Fort Lauderdale, Florida 33308

16695(eServed)

16696Alec J. Zavell, Esquire

16700Panza, Maurer, & Maynard, P.A.

16705Suite 905

167072400 East Commercial Boulevard

16711Fort Lauderdale, Florida 33308

16715(eServed)

16716Abigail Price - Williams, Esquire

16721Miami - Dade County

16725West Wing, Suite 109

167291611 Northwest 12th Avenue

16733Miami, Florida 33 136

16737Christopher Charles Kokoruda, Esquire

16741Miami - Dade County

16745West Wing, Suite 109

167491611 Northwest 12th Avenue

16753Miami, Florida 33136

16756(eServed)

16757Eugene Shy, Jr., Esquire

16761Miami - Dade County

16765West Wing, Suite 109

167691611 Northwest 12th Avenue

16773Miami, Florida 33136

16776( eServed)

16778Laura E. Wade, Esquire

16782Miami - Dade County

16786West Wing, Suite 109

167901161 Northwest 12th Avenue

16794Miami, Florida 33136

16797(eServed)

16798Craig D. Miller, Esquire

16802Rutledge Ecenia, P.A.

16805Suite 202

16807119 South Monroe Street

16811Tallahassee, Florida 32301

16814(eServed)

16815Paul C. Buckley, Esquire

16819Panza, Maurer, & Maynard, P.A.

16824Suite 905

168262400 East Commercial Boulevard

16830Fort Lauderdale, Florida 33308

16834(eServed)

16835Angelina Gonzalez, Esquire

16838Panza, Maurer, & Maynard, P.A.

16843Suite 905

168452400 East Commercial Boulevard

16849Fort Lauderdale, Flor ida 33308

16854(eServed)

16855Stephen C. Emmanuel, Esquire

16859Ausley & McMullen

16862123 South Calhoun Street

16866Tallahassee, Florida 32301

16869(eServed)

16870Gabriel F.V. Warren, Esquire

16874Rutledge Ecenia, P.A.

16877119 South Monroe Street, Suite 202

16883Tallahassee, Florida 32301

16886(eServed)

16887Lindsey L. Miller - Hailey, Esquire

16893Agency for Healthcare Administration

16897Mail Stop 7

169002727 Mahan Drive

16903Tallahassee, Florida 32308

16906(eServed)

16907Richard J. Shoop, Agency Clerk

16912Agency for Healthcare Administration

169162727 Mahan Drive, Mail Stop 3

16922Tallahassee, Florida 32308

16925(eServed)

16926Mary C. Mayhew, Secretary

16930Agency for Healthcare Administration

169342727 Mahan Drive, Mail Stop 1

16940Tallahassee, Florida 32308

16943(eServed)

16944Stefen Grow , General Counsel

16948Agency for Healthcare Administration

169522727 Mahan Drive, Mail Stop 3

16958Tallah assee, Florida 32308

16962(eServed)

16963K im Kellum , Esquire

16967Agency for Healthcare Administration

169712727 Mahan Drive, Mail Stop 3

16977Tallahassee, Florida 32308

16980(eServed)

16981Thomas M. Hoeler, Esquire

16985Agency for Healthcare Administration

169892727 Mahan Drive, Mail Stop 3

16995Tallahassee, Florida 32308

16998(eServed)

16999NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

17005All parties have the right to submit written exceptions within

1701515 days from the date of this Recommended Order. Any exceptions

17026to this Recommended Order should be filed with the agency that

17037will issue the Final Order in this case.

Select the PDF icon to view the document.
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Date
Proceedings
PDF:
Date: 04/30/2019
Proceedings: Recommended Order
PDF:
Date: 04/30/2019
Proceedings: Recommended Order cover letter identifying the hearing record referred to the Agency.
PDF:
Date: 04/30/2019
Proceedings: Recommended Order (hearing held September 10-14, 17-21 and 24-26, 2018). CASE CLOSED.
PDF:
Date: 01/18/2019
Proceedings: Notice of Joint Filing Proposed Recommended Order filed.
PDF:
Date: 01/18/2019
Proceedings: Tenet's Proposed Recommended Order filed.
PDF:
Date: 01/18/2019
Proceedings: Proposed Recommended Order of Jackson Hospital West filed.
PDF:
Date: 01/18/2019
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Notice of Filing Proposed Recommended Order filed.
PDF:
Date: 01/18/2019
Proceedings: Agency's Notice of Non-filing of Proposed Recommended Order filed.
PDF:
Date: 01/10/2019
Proceedings: Order Granting Extension of Time.
PDF:
Date: 01/07/2019
Proceedings: Unopposed Motion for Extension of Time to File Proposed Recommended Orders filed.
PDF:
Date: 12/07/2018
Proceedings: Order Granting Extension of Time.
PDF:
Date: 12/05/2018
Proceedings: Unopposed Motion for Extension of Time to File Proposed Recommended Orders filed.
PDF:
Date: 11/02/2018
Proceedings: Notice of Filing Transcript.
PDF:
Date: 10/15/2018
Proceedings: Notice of Filing Additional Pleading to Supplement File filed.
PDF:
Date: 10/08/2018
Proceedings: Order Granting Extension of Time.
PDF:
Date: 10/05/2018
Proceedings: East Florida-DMC, Inc. and Kendall Regional Medical Center's Motion for Extension of Time filed.
PDF:
Date: 09/25/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Notice of Filing filed.
PDF:
Date: 09/13/2018
Proceedings: Notice of Appearance (Lindsey Miller-Hailey) filed.
PDF:
Date: 09/11/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Response in Opposition to Tenet's Motion for Official Recognition or, in the alternative, Notice of Objection to the Use of Hearsay Evidence Contained within the Administrative Orders filed.
PDF:
Date: 09/07/2018
Proceedings: Notice of Filing East Florida-DMC, Inc. and Kendall Regional Medical Center's Amended Exhibit List filed.
PDF:
Date: 09/07/2018
Proceedings: Notice of Depositions Duces Tecum filed.
PDF:
Date: 09/07/2018
Proceedings: Cross-Notice of Taking Deposition Duces Tecum (Patricia Greenberg) filed.
PDF:
Date: 09/07/2018
Proceedings: Joint Pre-hearing Stipulation filed.
PDF:
Date: 09/07/2018
Proceedings: Tenet's Motion for Official Recognition filed.
PDF:
Date: 09/05/2018
Proceedings: Amended Notice of Taking Telephonic Depositions Duces Tecum (Levitt, Balsano, Knapp) filed.
PDF:
Date: 09/05/2018
Proceedings: Cross Notice of Taking Telephonic Depositions Duces Tecum (Weiner, Sullivan) filed.
PDF:
Date: 09/05/2018
Proceedings: Notice of Taking Telephonic Depositions Duces Tecum (Levitt, Balsano, Knapp) filed.
PDF:
Date: 09/05/2018
Proceedings: Tenet's Joinder in East Florida DMC's and Kendall Regional Medical Center's Response in Opposition to Public Health Trust's Motion in Limine filed.
PDF:
Date: 09/04/2018
Proceedings: Notice of Taking Telephonic Deposition Duces Tecum (Weiner and Sullivan; filed in Case No. 16-003820CON).
PDF:
Date: 09/04/2018
Proceedings: East Florida DMC's and Kendall Regional Medical Center's Response in Opposition to Public Health Trust's Motion in Limine filed.
PDF:
Date: 09/04/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Supplemental Motion in Limine to Exclude Evidence Improperly Applying or Adopting the Findings of Fact or Conclusions of Law of other Administrative Proceedings to this Matter filed.
PDF:
Date: 08/31/2018
Proceedings: Notice of Taking Deposition Duces Tecum (Iler) filed.
PDF:
Date: 08/30/2018
Proceedings: Order Granting Extension of Time.
PDF:
Date: 08/30/2018
Proceedings: Joint Motion for Extension of Time to File the Joint Pre-hearing Stipulation filed.
PDF:
Date: 08/27/2018
Proceedings: Motion in Limine and Notice of Objection as to Tenet's Exhibits (Patricia Greenberg's Deposition Exhibits No. 4 and 5) and Any Related Testimony (filed in Case No. 16-003820CON).
PDF:
Date: 08/27/2018
Proceedings: Amended Motion in Limine and Notice of Objection as to DMC's Exhibits (Bates Stamp Nos. DMC 2634 through DMC 2661) and any Related Testimony (filed in Case No. 16-003820CON).
PDF:
Date: 08/27/2018
Proceedings: Motion in Limine and Notice of Objection as to DMC's Exhibits (Bates Stamp Nos. DMC 2634 through DMC 2661) and any Related Testimony filed.
PDF:
Date: 08/27/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Amended Final Witness List filed.
PDF:
Date: 08/21/2018
Proceedings: Amended Notice of Taking Deposition Duces Tecum (Sullivan) filed.
PDF:
Date: 08/21/2018
Proceedings: Second Amended Notice of Taking Deposition Duces Tecum (Dan Sullivan) filed.
PDF:
Date: 08/21/2018
Proceedings: Notice of Retaining Court Reporter filed.
PDF:
Date: 08/20/2018
Proceedings: Notice of Cancellation of Deposition filed.
PDF:
Date: 08/17/2018
Proceedings: Amended Notice of Taking Deposition Duces Tecum (Joseph Averbach) (filed in Case No. 16-003820CON).
PDF:
Date: 08/16/2018
Proceedings: Amended Notice of Taking Deposition Duces Tecum (Jorge Perez; filed in Case No. 16-003820CON).
PDF:
Date: 08/16/2018
Proceedings: Order Granting in Part and Denying in Part Motion in Limine.
PDF:
Date: 08/16/2018
Proceedings: Intervenor Tenet's Amended Final Witness List filed.
PDF:
Date: 08/16/2018
Proceedings: Amended Notice of Depositions Duces Tecum (Balsano, Leavitt, and Knapp) filed.
PDF:
Date: 08/16/2018
Proceedings: Cross-Notice of Taking Depositions Duces Tecum (Platt, and Heggen) (filed in Case No. 16-003820CON).
PDF:
Date: 08/16/2018
Proceedings: Notice of Depositions Duces Tecum (Jimenez, Camps, Mederos, and Greenberg) filed.
PDF:
Date: 08/15/2018
Proceedings: Amended Notice of Taking Depositions Duces Tecum (Haushalter) filed.
PDF:
Date: 08/15/2018
Proceedings: Notice of Taking Depositions Duces Tecum (Platt, Heggen, Weiner, Sullivan) filed.
PDF:
Date: 08/15/2018
Proceedings: Notice of Taking Depositions Duces Tecum (Averbach) filed.
PDF:
Date: 08/15/2018
Proceedings: Amended Notice of Taking Depositions Duces Tecum (Balsano, Levitt, Knapp) filed.
PDF:
Date: 08/15/2018
Proceedings: Notice of Taking Depositions Duces Tecum (Jimenez, Camps, Mederos, Greenberg; filed in Case No. 16-003820CON).
PDF:
Date: 08/15/2018
Proceedings: Amended Notice of Taking Depositions Duces Tecum (Dan Sullivan; filed in Case No. 16-003820CON).
PDF:
Date: 08/13/2018
Proceedings: Amended Notice of Taking Depositions Duces Tecum filed.
PDF:
Date: 08/10/2018
Proceedings: Protective Order Regarding Confidential and Hipaa Items.
PDF:
Date: 08/09/2018
Proceedings: Joint Response in Opposition to Motion in Limine filed.
PDF:
Date: 08/08/2018
Proceedings: Notice of Taking Depositions Duces Tecum filed.
PDF:
Date: 08/08/2018
Proceedings: Amended Notice of Taking Depositions Duces Tecum (to correct address) filed.
PDF:
Date: 08/08/2018
Proceedings: Notice of Taking Depositions Duces Tecum filed.
PDF:
Date: 08/08/2018
Proceedings: Notice of Taking Depositions Duces Tecum filed.
PDF:
Date: 08/08/2018
Proceedings: Notice of Depositions Duces Tecum filed.
PDF:
Date: 08/08/2018
Proceedings: Jackson Hospital West's Email Privilege Log for Supplemental Response to Intervenors Request for Production served May 23, 2018 (filed in Case No. 16-003820CON).
PDF:
Date: 08/08/2018
Proceedings: Jackson Hospital West's Supplemental Response to Intervenors' First Request for Production served May 23, 2018 (filed in Case No. 16-003820CON).
PDF:
Date: 08/03/2018
Proceedings: Amended Agreed Motion for Entry of Protective Order regarding Confidential and HIPAA Items (as to Exhibit A case style) filed.
PDF:
Date: 08/03/2018
Proceedings: Amended Notice of Taking Depositions Duces Tecum filed.
PDF:
Date: 08/03/2018
Proceedings: Amended Notice of Depositions Duces Tecum filed.
PDF:
Date: 08/03/2018
Proceedings: Agreed Motion for Entry of Protective Order regarding Confidential and HIPAA Items filed.
PDF:
Date: 08/03/2018
Proceedings: The Public Health Trust's Motion in Limine to Exclude Evidence of Quality of Care, Availability of Resources to Accomplish and Operate Jackson West Proposal, Financial Feasibility, and Costs and Methods of Proposed Construction and Operation of Jackson West filed.
PDF:
Date: 08/01/2018
Proceedings: Notice of Taking Depositions Duces Tecum filed.
PDF:
Date: 08/01/2018
Proceedings: Notice of Depositions Duces Tecum filed.
PDF:
Date: 07/31/2018
Proceedings: The Agency for Health Care Administration's Final Witness List filed.
PDF:
Date: 07/31/2018
Proceedings: Intervenor Tenet's Final Witness List filed.
PDF:
Date: 07/31/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Final Witness List (filed in Case No. 16-003820CON).
PDF:
Date: 07/27/2018
Proceedings: Notice of Service of Kendall Regional Medical Center's Unverified Answers and Objections to Intervenors First Set of Interrogatories filed.
PDF:
Date: 07/27/2018
Proceedings: Notice of Service of East Florida-DMC, Inc.'s Unverified Answers and Objections to Jackson Memorial West's First Set of Interrogatories filed.
PDF:
Date: 07/27/2018
Proceedings: Notice of Service of Kendall Regional Medical Center's Unverified Answers and Objections to Jackson Memorial West's First Set of Interrogatories filed.
PDF:
Date: 07/27/2018
Proceedings: Kendall Regional Medical Center's Privilege Log to Intervenor's and Jackson Hospital West's First Request for Production of Documents filed.
PDF:
Date: 07/27/2018
Proceedings: Kendall Regional Medical Center's Response to Intervenor's First Request for Production of Documents filed.
PDF:
Date: 07/26/2018
Proceedings: East Florida-DMC, Inc.'s Response to Jackson Memorial West's First Request for Production of Documents filed.
PDF:
Date: 07/26/2018
Proceedings: Kendall Regional Medical Center's Response to Jackson Memorial West's First Request for Production of Documents filed.
PDF:
Date: 07/26/2018
Proceedings: East Florida-DMC, Inc.'s Response to Intervenor's First Request for Production of Documents filed.
PDF:
Date: 07/24/2018
Proceedings: East Florida-DMC, Inc. and Kendall Regional Medical Center's Final Witness List filed.
PDF:
Date: 07/24/2018
Proceedings: East-Florida-DMC, Inc.'s First Request for Production of Documents to Palmetto General Hoapital filed.
PDF:
Date: 07/24/2018
Proceedings: East Florida-DMC, Inc.'s First Request for Production of Documents to Coral Gables Hospital filed.
PDF:
Date: 07/24/2018
Proceedings: East Florida-DMC, Inc.'s First Request for Production of Documents to Hialeah Hospital filed.
PDF:
Date: 07/23/2018
Proceedings: Palmetto General's Notice of Service of Answers to First Interrogatories from Jackson Hospital West filed.
PDF:
Date: 07/23/2018
Proceedings: Palmetto General Hospital's Response to First Request for Production from Jackson Hospital West filed.
PDF:
Date: 07/23/2018
Proceedings: Hialeah Hospial's Notice of Service of Answers to First Interrogatories from Jackson Hospital West filed.
PDF:
Date: 07/23/2018
Proceedings: Hialeah Hospital's Response to First Request for Production from Jackson Hospital West filed.
PDF:
Date: 07/23/2018
Proceedings: Coral Gables' Notice of Service of Answers to First Interrogatories from Jackson Hospital West filed.
PDF:
Date: 07/23/2018
Proceedings: Coral Gables Hospital's Response to First Request for Production from Jackson Hospital West filed.
PDF:
Date: 07/20/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Privilege Log to East Florida-DMC, Inc.'s First Request for Production served May 25, 2018 filed.
PDF:
Date: 07/20/2018
Proceedings: Jackson Hospital West's Response to East Florida-DMC, Inc's First Request for Production served May 25, 2018 filed.
PDF:
Date: 07/17/2018
Proceedings: Notice of Appearance (Gabriel Warren) filed.
PDF:
Date: 07/03/2018
Proceedings: Jackson Hospital West's Notice of Serving Verified Answers to Tenet's First Interrogatories Served May 23, 2018 filed.
PDF:
Date: 07/02/2018
Proceedings: The Public Health Trust of Miami-Dade County, Florida's Preliminary Witness List filed.
PDF:
Date: 07/02/2018
Proceedings: The Agency for Health Care Administration's Preliminary Witness List filed.
PDF:
Date: 07/02/2018
Proceedings: Jackson Hospital West's Privilege Log to Tenet's Request for Production served May 23, 2018 filed.
PDF:
Date: 07/02/2018
Proceedings: Jackson Hospital West's Response to Tenet's First Request for Production served May 23, 2018 filed.
PDF:
Date: 07/02/2018
Proceedings: Jackson Hospital West's Notice of Serving Unverified Answers to Tenet's First Interrogatories served May 23, 2018 filed.
PDF:
Date: 07/02/2018
Proceedings: Intervenor Tenet's Preliminary Witness List filed.
PDF:
Date: 07/02/2018
Proceedings: East Florida-DMC, Inc. and Kendall Regional Medical Center's Preliminary Witness List filed.
PDF:
Date: 06/04/2018
Proceedings: Order of Pre-hearing Instructions.
PDF:
Date: 06/01/2018
Proceedings: Proposed Order of Pre-hearing Instructions filed.
PDF:
Date: 06/01/2018
Proceedings: Order Granting Motion to Intervene (CGH Hospital, Ltd. d/b/a Coral Gables Hospital, Tenet Hialeah Healthsystem, Inc. d/b/a Hialeah Hospital and Lifemark Hospitals, Inc. d/b/a Palmetto General Hospital).
PDF:
Date: 05/25/2018
Proceedings: East Florida-DMC, Inc.'s First Request for Production of Documents to Jackson Hospital West filed.
PDF:
Date: 05/25/2018
Proceedings: Jackson Hospital West's First Request for Production to Kendall Healthcare Group, Ltd., d/b/a Kendall Regional Medical Center filed.
PDF:
Date: 05/25/2018
Proceedings: Petitioner's, Jackson Hospital West, Notice of Serving First Set of Interrogatories to Kendall Healthgroup, Ltd. d/b/a Kendall Regional Medical Center filed.
PDF:
Date: 05/25/2018
Proceedings: Jackson Hospital West's First Request for Production to Lifemark Hospital, Inc., d/b/a Palmetto General Hospital filed.
PDF:
Date: 05/25/2018
Proceedings: Petitioner's, Jackson Hospital West, Notice of Serving First Set of Interrogatories to Lifemark Hospital, Inc., d/b/a Palmetto General Hospital filed.
PDF:
Date: 05/25/2018
Proceedings: Jackson Hospital West's First Request for Production to Tenet Hialeah Healthsystem, Inc., d/b/a Hialeah Hospital filed.
PDF:
Date: 05/25/2018
Proceedings: Petitioner's, Jackson Hospital West, Notice of Serving First Set of Interrogatories to Tenet Hialeah Healthsystem, Inc., d/b/a Hialeah Hospital filed.
PDF:
Date: 05/25/2018
Proceedings: Jackson Hospital West's First Request for Production to CGH Hospital, Ltd., d/b/a Coral Gables Hospital filed.
PDF:
Date: 05/25/2018
Proceedings: Petitioner's, Jackson Hospital West, Notice of Serving First Set of Interrogatories to CGH Hospital, Ltd., d/b/a Coral Gables Hospital filed.
PDF:
Date: 05/25/2018
Proceedings: Respondent, Jackson Memorial West's, First Request for Production to East Florida-DMC, Inc. filed.
PDF:
Date: 05/25/2018
Proceedings: Petitioner's, Jackson Hospital West, Notice of Serving First Set of Interrogatories to East Florida-DMC, Inc. filed.
PDF:
Date: 05/23/2018
Proceedings: Intervenors' Notice of Service of First Interrogatories to Jackson Hospital West filed.
PDF:
Date: 05/23/2018
Proceedings: Intervenors' First Request for Production of Documents to Jackson Hospital West filed.
PDF:
Date: 05/23/2018
Proceedings: Intervenors' Notice of Service of First Interrogatories to East Florida-DMC, Inc. filed.
PDF:
Date: 05/23/2018
Proceedings: Intervenors' First Request for Production of Documents to East Florida-DMC, Inc. filed.
PDF:
Date: 05/23/2018
Proceedings: Intervenors' Notice of Service of First Interrogatories to Kendall Healthcare Group, Ltd filed.
PDF:
Date: 05/23/2018
Proceedings: Intervenors' First Request for Production of Documents to Kendall Healthcare Group, Ltd. filed.
PDF:
Date: 05/18/2018
Proceedings: Order Requesting Proposed Order of Pre-hearing Instructions.
PDF:
Date: 05/18/2018
Proceedings: Notice of Hearing (hearing set for September 10 through 14, 17 through 21 and 24 through 28, 2018; 9:30 a.m.; Tallahassee, FL).
PDF:
Date: 05/17/2018
Proceedings: Notice of Appearance (Stephen Emmanuel) filed.
Date: 05/17/2018
Proceedings: CASE STATUS: Pre-Hearing Conference Held.
PDF:
Date: 05/16/2018
Proceedings: Notice of Telephonic Status Conference (status conference set for May 17, 2018; 11:30 a.m.).
PDF:
Date: 05/10/2018
Proceedings: Joint Status Report filed.
PDF:
Date: 04/24/2018
Proceedings: Order Continuing Case in Abeyance (parties to advise status by May 21, 2018).
PDF:
Date: 04/20/2018
Proceedings: Joint Status Report filed.
PDF:
Date: 03/13/2018
Proceedings: Order Continuing Case in Abeyance (parties to advise status by April 20, 2018).
PDF:
Date: 03/13/2018
Proceedings: Joint Status Report filed.
PDF:
Date: 02/13/2018
Proceedings: Order Continuing Case in Abeyance (parties to advise status by March 13, 2018).
PDF:
Date: 02/09/2018
Proceedings: Joint Status Report (filed in Case No. 16-003820CON).
PDF:
Date: 01/10/2018
Proceedings: Order Continuing Case in Abeyance (parties to advise status by February 12, 2018).
PDF:
Date: 01/09/2018
Proceedings: Joint Status Report (filed in Case No. 16-003820CON).
PDF:
Date: 01/03/2018
Proceedings: Order Continuing Case in Abeyance (parties to advise status by January 10, 2018).
PDF:
Date: 12/01/2017
Proceedings: Joint Status Report filed.
PDF:
Date: 11/21/2017
Proceedings: Order (granting Intervenor Variety Children's Hospital d/b/a Nicklaus Children's Hospital dismissal).
PDF:
Date: 11/20/2017
Proceedings: Nicklaus Children's Hospital's Notice of Voluntary Dismissal filed.
PDF:
Date: 11/07/2017
Proceedings: Order Continuing Case in Abeyance (parties to advise status by December 1, 2017).
PDF:
Date: 10/31/2017
Proceedings: Joint Status Report (filed in Case No. 16-003820CON).
PDF:
Date: 10/02/2017
Proceedings: Order Continuing Case in Abeyance (parties to advise status by November 1, 2017).
PDF:
Date: 09/29/2017
Proceedings: Joint Status Report (filed in Case No. 16-003820CON).
PDF:
Date: 08/30/2017
Proceedings: Order Continuing Case in Abeyance (parties to advise status by October 2, 2017).
PDF:
Date: 08/30/2017
Proceedings: Joint Status Report filed.
PDF:
Date: 06/01/2017
Proceedings: Order Continuing Case in Abeyance (parties to advise status by September 1, 2017).
PDF:
Date: 05/26/2017
Proceedings: Joint Status Report filed.
PDF:
Date: 04/10/2017
Proceedings: Order Continuing Cases in Abeyance (parties to advise status by May 26, 2017).
PDF:
Date: 04/06/2017
Proceedings: Joint Status Report and Continued Request to Keep Case in Abeyance filed.
PDF:
Date: 02/06/2017
Proceedings: Order Continuing Case in Abeyance (parties to advise status by April 6, 2017).
PDF:
Date: 02/01/2017
Proceedings: Joint Status Report and Continued Request to Keep Case in Abeyance filed.
PDF:
Date: 10/18/2016
Proceedings: Order Continuing Cases in Abeyance (parties to advise status by February 1, 2017).
PDF:
Date: 10/18/2016
Proceedings: Joint Status Report and Request to Keep Case in Abeyance filed.
PDF:
Date: 07/22/2016
Proceedings: Notice of Appearance (Sabrina Dieguez) filed.
PDF:
Date: 07/20/2016
Proceedings: Notice of Appearance (Angelina Gonzalez) filed.
PDF:
Date: 07/20/2016
Proceedings: Notice of Appearance (Paul Buckley) filed.
PDF:
Date: 07/20/2016
Proceedings: Order Placing Cases in Abeyance (parties to advise status by October 20, 2016).
PDF:
Date: 07/20/2016
Proceedings: Order Granting Motion to Intervene.
PDF:
Date: 07/20/2016
Proceedings: Order Granting Motion to Intervene.
PDF:
Date: 07/19/2016
Proceedings: Notice of Appearance (Elizabeth Penderson) filed.
PDF:
Date: 07/19/2016
Proceedings: Motion to Intervene (filed by The Public Health Trust of miami-Dade County, Florida d/b/a Jackson Hospital West) filed.
PDF:
Date: 07/19/2016
Proceedings: Notice of Appearance (Thomas Panza) filed.
PDF:
Date: 07/19/2016
Proceedings: Order of Consolidation (DOAH Case Nos. 16-3819CON and 16-3820CON).
PDF:
Date: 07/19/2016
Proceedings: Amended Joint Motion for Abeyance filed.
PDF:
Date: 07/19/2016
Proceedings: Order Granting Motion to Intervene.
PDF:
Date: 07/18/2016
Proceedings: Joint Unopposed Motion for Abeyance filed.
PDF:
Date: 07/07/2016
Proceedings: Notice of Appearance (Eugene Rivers) filed.
PDF:
Date: 07/07/2016
Proceedings: Motion to Intervene (CGH Hospital, Ltd., d/b/a Coral Gables Hospital, Tenent Hialeah Healthsystem, Inc., d/b/a Hialeah Hospital and Lifemark Hospitals, Inc., d/b/a Palmetto General Hospital) filed.
PDF:
Date: 07/07/2016
Proceedings: Notice of Appearance (Michael Glazer) filed.
PDF:
Date: 07/06/2016
Proceedings: Initial Order.
PDF:
Date: 07/05/2016
Proceedings: Decision on Batched General Hospital Application filed.
PDF:
Date: 07/05/2016
Proceedings: Letter to Marisol Fitch from April Andrews-Singh regarding oppostion of East Florida-DMC,Inc.'s Certificate of Need filed.
PDF:
Date: 07/05/2016
Proceedings: Nicklaus Children's Hospital's Petition for Leave to Intervene filed.
PDF:
Date: 07/05/2016
Proceedings: Petition for Formal Administrative Proceeding filed.
PDF:
Date: 07/05/2016
Proceedings: Notice (of agency referral) filed.

Case Information

Judge:
W. DAVID WATKINS
Date Filed:
07/05/2016
Date Assignment:
07/05/2016
Last Docket Entry:
04/30/2019
Location:
Tallahassee, Florida
District:
Northern
Agency:
Agency for Health Care Administration
Suffix:
CON
 

Counsels

Related Florida Statute(s) (7):