17-003108RX Venice Hma Hospital, Llc, D/B/A Venice Regional Bayfront Health vs. Agency For Health Care Administration Status: Closed DOAH Final Order on Tuesday, May 8, 2018.

Summary: Rule 59C-1.008(4)(c) is an invalid exercise of delegated legislative authority.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

VENICE HMA HOSPITAL, LLC, d/b/a

VENICE REGIONAL BAYFRONT HEALTH,

Petitioner,

vs. Case No. 17 - 3108RX

AGENCY FOR HEALTH CARE

ADMINISTRATION,

Respondent,

and

SARASOTA COUNTY PUBLIC HOSPITAL

DISTRICT, d/b/a SARASOTA

MEMORIAL HOSPITAL,

Intervenor.

_______________________________/

FINAL ORDER

Pursuant to notice, the Division of Administrative

Hearings, by its designated Administrative Law Judge, W. David

Watkins, held a formal hearing in the above - styled case on

September 19 and 22 , 2017, in Tallahassee, Florida.

APPEARANCES

For Venice HMA Hospital, LLC d/b/a Venice Regional Bayfront

Health:

Geoffrey D. Smith, Esquire

Susan C. Smith, Esquire

Smith & Associates

3301 Thomasville Road, Suite 201

Tallahassee, Florida 32308

For the Agency for Health Care Administration:

Richard Joseph Saliba, Esquire

Kevin M ichael Marker, Esquire

Lindsey L. Miller - Hailey, Esquire

Agency for Health Care Administration

Fort Knox Building III, Mail Stop 7

27 27 Mahan Drive

Tallahassee, Florida 32308

For Sarasota County Public Hospital District , d/b/a

Sarasota Memorial Hospital:

D. Ty Jackson, Esquire

Allison G. Mawhinney, Esquire

J. Michael Huey, Esquire

GrayRobinson, P.A.

301 South Br onough Street, Suite 600

Tallahassee, Florida 32301

STATEMENT OF THE ISSUE

Whether Florida Administrative Co de Rule 59C - 1.008(4)

(Rule) constitutes an invalid exercise of delegated legislative

authority because it enlarges, modifies, or contravenes the

specif ic provisions of law implemented.

PRELIMINARY STATEMENT

This Rule challenge proceeding was initiated on May 25,

2017, when Venice HMA Hospital, LLC , d/b/a Venice Regional

Bayfront Health (VRBH ) , filed a pleading captioned ÐPetition to

Determine the Invali dity of Rule 59C - 1.008(4)Ñ ( Petition)

against the Agency for Health Care Administration ( AHCA ) at the

Division of Administrative Hearings (DOAH).

The Petition challenges the Rule as an invalid exercise of

delegated legislative authority in that it enlarges , modifies,

or contravenes the specific provisions of law implemented .

According to VRBH, it does so by requiring applicants for a

general hospital certificate of need ( CON ) to provide

information that VRBH contends the statutes clearly do not

require, to wit , audited financial statements for the applicant

or the applicantÓs parent.

Background

Sarasota County Public Hospital District , d/b/a Sarasota

Memorial Hospital (SMH) , and VRBH both filed CON applications

for general hospitals in AHCA Subdistrict 8 - 6 , Sarasota County ,

in the second batching cycle of 2016. Following AHCA Ós

preliminary approval of both CON applications, petitions were

filed by sev eral parties challenging those approvals .

Ultimately, the petitions were referred to DOAH as Case N os. 17 -

0510CON, 17 - 0551CON, 17 - 0553CON, 17 - 0556CON, and 17 - 0557CON

(referred to collectively as the ÐCON casesÑ) and were

consolidated.

Prior to the final hearing in the CON cases, VRBH filed a

m ot ion in l imine to exclude testimony as to the inadequacy of

its CON application with respect to its audited financial

statements. VRBH argued the applicable statutes, specifically

sections 408.035 and 408.037, Florida Statutes, 1/ did not require

general hospital applicants to submit audited financial

statements with their CON applications.

Th e filing of the Rule challenge Petition was precipitated

by the undersignedÓs ruling on the motion in limine in the CON

cases , which included the statement that Ð[b]y its express

terms, the requirements of [the Rule] are applicable to [VRBHÓs]

application, and the extent to which [VRBHÓs] application

complied with the ruleÓs application content requirements is a

relevant inquiry in this proceeding.Ñ Order Denying Motion in

Limine, Sarasota Mem Ó l Hosp . v. Venice Reg Ó l Bayf ront Health ,

Case No. 17 - 0556CON (Fla. DOAH May 22, 2017).

After VRBH received this adverse ruling in the CON cases,

the instant Rule challenge was filed on May 25, 2017.

VRBH challenges r ule 59C - 1.008(4) as an invalid exercise of

delegated legislative a uthority on the grounds that the Rule

enlarges, modifies, or contravenes the specific provisions of

law implemented in violation of section 120.52(8)(c), Florida

Statutes. No other grounds for the alleged invalidity were

pled.

On May 26, 2017, VRBH moved to consolidate the Rule

challenge with the CON cases. On May 31, 2017, SMH moved to

intervene , which motion was subsequently granted .

On June 1, 2017, AHCA moved to dismiss the Rule c hallenge .

AHCA argued that VRBH was not sub stantially affected and lacked

standing because AHCA interprets the Rule as not requiring VRBH

to submit an audited financial statement. VRBH and SMH

responded to AHCAÓs Motion to Dismiss on June 7, 2017, and

June 8, 2017 , respectively.

On June 21, 2017, the undersigned denied AHCAÓs Motion to

Dismiss, consolidated the Rule challenge with the CON cases for

purposes of hearing only , and ordered that the final hearing for

the Rule challenge be held concurrently with the CON cases.

The fina l hearing on the consolidated cases was held on

August 7 through 11, August 14 through 18, August 21 through 25,

and September 19 and 22, 2017. The portion of the final hearing

specifically addressing the R ule challenge oc curred primarily on

September 19 and 22 , 2017.

At the final hearing portion dedicated to the Rule

challenge , VRBH presented the testimony of Patricia Greenberg

and AHCA presented the testimony of Marisol Fitch. The final

hearing transcript pages dedicated to the Rule challenge are

pages 4457 - 4497, 4678 - 4686, 4718 - 4725, and 4825 - 4863. V RBH

offered its exhibits 196 - 200, which were received into evidence.

Two a dditional VR BH exhibits that are related to the Rule

challenge received into evidence during the CON portion of the

final hearing are VRBH Ós Exhibits 135 and 136. AHCA offered its

exhibit 2, which was received into evidence.

The official T ranscript of the final hearing was filed at

DOAH on October 23, 2017 . O n November 29, 2017, AHCA, VRBH , and

SMH timely filed Proposed Final Orders , each of which has been

carefully considered in the preparation of this Final Order.

FINDINGS OF FACT

The Parties

1. VRBH is an existing hospital in Sarasota County. In

the second batching cycle of 2016, VRBH applied to AHCA for a

CON to establish a Class I Acute Care Replacement Hospital of up

to 312 beds in AHCA District VIII, Subdistrict 8 - 6, Sarasota

County. The CON application was preliminarily approved by AHCA

on December 2, 2016.

2 . SMH is a public hospital system serving Sarasota

County. In the second batching cycle of 2016, SMH applied for a

CON to establish a new acute care hospital with 90 beds in AHCA

District 8, Acute Care Subdistrict 8 - 6, Sarasota County. As

with the VRBH applicati on, t he SMH application also received

preliminar y approv al from AHCA on December 2, 2016.

3 . AHCA is designated as the single state agency

responsible for administering the CON program under the Health

Facility and Services Development Act, sections 408.031

through 408.045, Florida Statutes.

The Challenged Rule

4 . In part, Florida Administrative Code Rule 59C - 1.008(4)

requires that CON applications contain the audited financi al

statements of the applicant, or the applicantÓs parent

corporation. The Rule states as follows:

(4) Certificate of Need Application

Contents. An application for a Certificate

of Need shall contain the following items:

(a) All requirements set forth in Sections

408.037(1), (2) and (3), F.S.

(b) The correct application fee.

(c) An audited financial statement of the

applicant or the applicantÓs parent

corporation if the applicantÓs audited

financial statements do not exis t. The

following provisions apply:

1. The audited financial statement of the

applicant, or the applicantÓs parent

corporation, must be for the most current

fiscal year. If the most recent fiscal year

ended within 120 days prior to the

application filin g deadline and the audited

financial statements are not yet available,

then the prior fiscal year will be

considered the most recent.

2. Existing health care facilities must

provide audited financial statements for the

two most recent consecutive fiscal years in

accordance with subparagraph 1. above.

3. Only audited financial statements of the

applicant, or the applicantÓs parent

corporation, will be accepted. Audited

financial statements of any part of the

applicant or the applicantÓs parent

corporati on, including but not limited to

subsidiaries, divisions, specific facilities

or cost centers, will not qualify as an

audit of the applicant or the applicantÓs

parent corporation.

(d) To comply with Section 408.037(1)(b)1.,

F.S., which requires a listing of all

capital projects, the applicant shall

provide the total approximate amount of

anticipated expenditures for capital

projects which meet the definition in

subsection 59C - 1.002(7), F.A.C., at the time

of initial application submission, or state

that t here are none. An itemized list or

grouping of capital projects is not

required, although an applicant may choose

to itemize or group its capital projects.

The applicant shall also indicate the actual

or proposed financial commitment to those

projects, a nd include an assessment of the

impact of those projects on the applicantÓs

ability to provide the proposed project;

and,

(e) Responses to applicable questions

contained in the application forms.

The 2008 CON Legislative Changes

5. In 2008, the Florida Legislature made numerous changes

to streamline the CON application process for general hospitals.

It is these changes that VRBH asserts removed the requirement

for general hospitals to submit audited financial statements

with CON applications. Section 408.035 was amended to provide

as follows:

408.035 Review criteria. Ï

(1) The agency shall determine the

reviewability of applications and shall

review applications for certificate - of - need

determinations for health care facilities

and health services in c ontext with the

following criteria, except for general

hospitals as defined in s. 395.002 :

(a) The need for the health care facilities

and health services being proposed.

(b) The availability, quality of care,

accessibility, and extent of utilization of

existing health care facilities and health

services in the service district of the

applicant.

(c) The ability of the applicant to provide

quality of care and the applicantÓs record

of providing quality of care.

(d) The availability of resources,

inclu ding health personnel, management

personnel, and funds for capital and

operating expenditures, for project

accomplishment and operation.

(e) The extent to which the proposed

services will enhance access to health care

for residents of the service distric t.

(f) The immediate and long - term financial

feasibility of the proposal.

(g) The extent to which the proposal will

foster competition that promotes quality and

cost - effectiveness.

(h) The costs and methods of the proposed

construction, including the costs and

methods of energy provision and the

availability of alternative, less costly, or

more effective methods of construction.

(i) The applicantÓs past and proposed

provision of health care services to

Medicaid patients and the medically

indigent.

(j) The applicantÓs designation as a Gold

Seal Program nursing facility pursuant to

s. 400.235, when the applicant is requesting

additional nursing home beds at that

facility.

(2) For a general hospital, the agency

shall consider only the criteria specified

in paragraph (1)(a), paragraph (1)(b),

except for quality of care in paragraph

(1)(b), and paragraphs (1)(e), (g), and (i).

(Emphasis added) .

6. Section 408.035 has not been revised since 2008.

7. Additionally, section 408.037 was amended to read as

follows:

408.037 Application content. Ï

(1) Except as provided in subsection (2)

for a general hospital , an application for a

certificate of need must contain:

(a) A detailed description of the proposed

project and statement of its purpose and

need in relation to the district health

plan.

(b) A statement of the financial resources

needed by and available to the applicant to

accomplish the proposed project. This

statement must include:

1. A complete listing of all capital

projects, including new health facility

development projects and health facility

acquisitions applied for, pending, approved,

or underway in any state at the time of

application, regardless of whether or not

that state has a certificate - of - need program

or a capital expenditure review program

pursuant to s. 1122 of the Social Security

Act. The agency may, by rule, require less -

detailed information from major health care

providers. This listing must include the

applican tÓs actual or proposed financial

commitment to those projects and an

assessment of their impact on the

applicantÓs ability to provide the proposed

project.

2. A detailed listing of the needed capital

expenditures, including sources of funds.

3. A detailed financial projection,

including a statement of the projected

revenue and expenses for the first 2 years

of operation after completion of the

proposed project. This statement must

include a detailed evaluation of the impact

of the proposed p roject on the cost of other

services provided by the applicant.

(c) An audited financial statement of the

applicant or the applicantÓs parent

corporation if audited financial statements

of the applicant do not exist . In an

application submitted by an ex isting health

care facility, health maintenance

organization, or hospice, financial

condition documentation must include, but

need not be limited to, a balance sheet and

a profit - and - loss statement of the

2 previous fiscal yearsÓ operation.

(2) An applic ation for a certificate of

need for a general hospital must contain a

detailed description of the proposed general

hospital project and a statement of its

purpose and the needs it will meet. The

proposed projectÓs location, as well as its

primary and seco ndary service areas, must be

identified by zip code. Primary service

area is defined as the zip codes from which

the applicant projects that it will draw 75

percent of its discharges. Secondary

service area is defined as the zip codes

from which the appl icant projects that it

will draw its remaining discharges. If,

subsequent to issuance of a final order

approving the certificate of need, the

proposed location of the general hospital

changes or the primary service area

materially changes, the agency shal l revoke

the certificate of need. However, if the

agency determines that such changes are

deemed to enhance access to hospital

services in the service district, the agency

may permit such changes to occur. A party

participating in the administrative hear ing

regarding the issuance of the certificate of

need for a general hospital has standing to

participate in any subsequent proceeding

regarding the revocation of the certificate

of need for a hospital for which the

location has changed or for which the

pri mary service area has materially changed.

In addition, the application for the

certificate of need for a general hospital

must include a statement of intent that, if

approved by final order of the agency, the

applicant shall within 120 days after

issuance of the final order or, if there is

an appeal of the final order, within 120

days after the issuance of the courtÓs

mandate on appeal, furnish satisfactory

proof of the applicantÓs financial ability

to operate . The agency shall establish

documentation req uirements, to be completed

by each applicant, which show anticipated

provider revenues and expenditures, the

basis for financing the anticipated cash -

flow requirements of the provider, and an

applicantÓs access to contingency financing.

A party participat ing in the administrative

hearing regarding the issuance of the

certificate of need for a general hospital

may provide written comments concerning the

adequacy of the financial information

provided, but such party does not have

standing to participate in a n administrative

proceeding regarding proof of the

applicantÓs financial ability to operate .

The agency may require a licensee to provide

proof of financial ability to operate at any

time if there is evidence of financial

instability, including, but not l imited to,

unpaid expenses necessary for the basic

operations of the provider.

(3) The applicant must certify that it will

license and operate the health care

facility. For an existing health care

facility, the applicant must be the

licenseholder of the facility.

(Emphasis added) .

8 . Section 408.037 has only been amended once since 2008.

The revisions are not relevant to the issue presented in this

Rule challenge. 2 /

The PartiesÓ Positions

9 . In support of its argument that the Rule contravenes

the statutes, VRBH asserts that the Rule is an invalid exercise

of delegated legislative authority because it enlarges,

modifies, or contravenes the laws implemented. Simply put, VRBH

contend s that the Rule is contrary to sections 408.035 and

408.037 . VRBH advance s three reasons for its position that the

Rule modifies the laws implemented; all three center on the

assertion that in 2008 , the Legislature removed the requirement

for the submission of audited financial statements with general

hospital CON applica tions :

(1) Requiring a general hospital to comply

with the requirements of section 408.037(1),

Florida Statutes, by submitting an audited

financial statement with its CON application

violates the express provision of the

statute which specifically excludes general

hospitals from the requirements of

subsection (1);

(2) Requiring a general hospital to submit

an audited financial statement with the CON

application directly contradicts the

submis sion requirements set forth in section

408.037(2), Florida Statutes, which only

requires a general hospital to provide a

statement of intent that it will Ðfurnish

satisfactory proof of the applicantÓs

financial ability to operateÑ if the CON

application is approved by final order of

the agency.

(3) Requiring a general hospital to submit

an audited financial statement with the CON

application contradicts the 2008 legislative

changes to section 408.035, Florida

Statutes, which streamlined the application

process for general hospitals by removing

the short and long term financial

feasibility of the project as a review

criteria .

(VRBH Petition, ¶¶ 15 - 17) .

10 . AHCA Ós ultimate position is that the Rule should be

interpreted as not requiring audited financial statements for

g eneral hospital CON applicants . To reach this conclusion, AHCA

relies on 59C - 1.008(4)(a) , which provides that a CON application

must contain Ðall requirements set forth in Sections 408.037(1),

(2), and (3), Florida Statutes.Ñ

11 . AHCA interprets the introductory phrase contained in

section 408.037(1) -- Ðexcept as provided in subsection (2) for a

general hospital, an application for a certificate of need must

containÑ -- to mean that only subsection (2) of section 408.037

applies to an application for general hospitals. Because

section 408.037(2) does not mention audited financial

statements, AHCA reasons that they are not required.

12 . Therefore, despite the plain language of the Rule,

AHCA contends that the Rule does not require the submission of

audited financial statements because : the Rule references

sections 408.037(1), (2), and (3) ; AHCA interprets only section

408.037(2) as applying to general hospitals ; and section

408.037(2) does not mention audited financial statements.

13 . SMH contends that the Rule does not enlarge, modify,

or contravene the laws implemented and , therefore , is a valid

e xercise of delegated legislative authority. Specifically, SMH

contends that section 408.037 itself requires general hospital

applicants to submit audited financial statements because

subsection (2) does not wholesale replace subsection (1) for

general hospitals. Subsection (1) applies to general hospitals ,

unless there is an exception to those requirements listed in

subsection (2). Subsection (1) requires the submission of

audited financial statements for all CON applicants; nothing in

subsection (2) creates an exception to that requirement.

14 . SMH also argues that audited financial statements are

reliable documents that AHCA can quickly access for relevant

information, including an applicantÓs provision of health care

services to Medicaid patients and the medically indigent, both

of which are prominent considerations during the review of a

general hospitalÓs CON application. See § 408.035(1)(i), (2),

Fla. Stat .

Post 2008 Rule

15 . Challenged Rule 59C - 1.008(4) does not expressly

exclude or differentiate between general hospital CON

applications and other CON applications. Instead the Rule

cross - references to the statutory requirement. AHCA asserts

that by doing so, the R ule incorpo rates the statutory scheme by

reference and does not require a CON application for a general

hospital to include audited financial statements.

16 . The above - cited statutory provisions clear ly state

that a general hospital CON application need not include an

audited financial statement and that financial condition is not

relevant to the CON application review process.

17 . Any rule that requires a general hospital CON

applicant to provide an audited financial statement with the

application would be c ontrary to the requirements of section

408.037. It follows, t herefore, that a rule contrary to the

requirements of a statute would be invalid as it would exceed

AHCAÓs delegated l egislative authority.

18 . Requiring a general hospital applicant to c omply with

th e requirements of section 408.037(1) would violate the

provision of the statute, which expressly excludes general

hospitals from the requirements of subsection (1).

19 . F urther, requiring a general hospital applicant to

submit an audited financial statement with its CON application

directly contradicts the submission requirements set forth in

section 408.037(2).

20 . AHCAÓs interpretation of r ule 59C - 1.008 is that it

must be read in conjunction with section 408.037,

subs ections (1), (2), and (3), and accordingly, AHCA do es not

require that a general hospital applicant submit an audited

financial statement as part of its application .

21 . AHCAÓs interpretation is consistent with the

differences in the content of the CON ap plication forms

published by AHCA for general hospital applications when

compared to non - general hospital applications, for instance,

those seeking other beds and services such as comprehensive

medical rehabilitation, psychiatric, hospice, and other CON -

regulated beds in a hospital. The requirements of each

application type correspond to the statutory requirements for

each application type.

22 . Application forms for projects Ðexcept for general

hospitalsÑ correspond to the CON application content

re quirements of section 408.037(1) , which require s a statement

of financial resources that must include capital projects

(Schedule 2 of the CON application); capital expenditures and

source of funds (Schedules 1 and 3 of the CON application); and

a detailed financial projection, including revenues and expenses

for the first two years (Schedules 5 through 8 of the CON

application). The general hospital CON application does not

have these requirements.

23 . General hospitals are not required to submit proof o f

financial ability to operate at the time of the submission of

the CON application. In accordance with r ule 59C - 1.010(2)(d),

general hospitals are required to comply with the re quirements

of sections 408.035(2) and 408.037(2) . Neither of th ose

statutes requires that a general hospital applicant submit proof

of financial ability to operate until 120 days after the

issuance of the final CON to the applicant.

24 . AHCAÓs representative, Marisol Fitch, testified that

AHCA does not require applicants for gene ral hospitals to submit

audited financial statements in the CON application, and that

proof of financial ability to operate is required within

120 days after the final approval of the CON application,

consistent with the statutory provisions. She testifie d that

the Rule being challenged , when read in conjunction with the

AHCA CON application form (incorporated by reference into the

Rule) and other AHCA ru les, including 59C - 1.010 and 59C - 1.030,

is consistent with the statute, and that no audited financial

s tatements are required.

25 . SMH asserts that an audited financial statement for

hospitals might contain useful information, such as information

on a hospitalÓs current payor mix. However, the unrefuted

testimony is that audited financial statements are n ot required

to include payor mix information, and normally do not since they

are typically used to look at an applicantÓs financial

feasibility to operate. Further, regardless of whether such

information might be Ðuseful ,Ñ the specific requirement of

s ection 408.037(2) expressly ÐexceptsÑ general hospitals from

the requirement to include such statements in the CON

application.

26 . Pursuan t to r ule 59C - 1.010(2)(d) , Ð an application for

a general hospital must meet the requirements of Sections

408.035(2) and 408.037(2), F.S. , Ñ neither of which require that

a general hospital CON applicant provide audited financials or

financial feasibility data with the CON application.

27 . However, the challenged langu age in r ule 59C - 1.008(4)

does not contain the Ðexce ptionÑ for general hospital

applications. Rule 59C - 1.008(4) provides, without

qualification, that a CON application must conta in audited

financial statements. T herefore , r ules 59C - 1.008(4) and

59C - 1.010(2)(d) are contradictory .

28 . The primary purpose of an audited financial statement

in a CON application is to review the short - term and long - term

financial feasibility of the proposal. Requiring this financial

information is contrary to the clear language of the 2008

changes to section 408.035, which removed the short - term and

long - term financial feasibility of the project as review

criteria in order to streamline the general hospital CON

application process.

29 . AHCA has state d that their interpretation of r ule

59C - 1.008(4) is that it must be read in pari materia with r ule

59C - 1.010(2)(d) and sections 408.037 and 408.035, therefore ,

general hospital CON applicants are not required to submit

audited financials with the CON application. Accor ding to

AHCAÓs interpr etation, r ule 59C - 1.008(4) does not require a

general hospital CON applicant to submit an audited financial

statement with the CON application. However, regardless of

AHCAÓs interpretation, r ule 59C - 1.008(4) expressly states that a

CON application must co ntain audited financial statements , in

contravention of sections 408.035 and 408.037 .

CONCLUSIONS OF LAW

30 . DOAH has jurisdiction over the parties and the subject

matter of this proceeding. § 120.56(1) and (3), Fla. Stat. Any

person who is substantially affected by a rule or proposed rule

can petition DOAH for a f inal o rder that the rule or proposed

rule is an invalid exercise of delegated legislative authority.

§ 120.56(1)(a), Fla. Stat.

31 . As the party challenging t he validity of r ule 59C -

1.008(4) , VRBH has the burden of proving by a preponderance of

the evidence that the Rule is an invalid exercise of delegated

legislative authority as to the objections raised.

§ 1 20.56(3)(a) , Fla. Stat . Unlike a challenge to a proposed

rule, the burden of proof never shifts to AHCA . § 120.56(2)

& (3), Fla. Stat.; see Bd. o f Clinical Lab. Personnel v. Fla.

AssÓn of Blood Banks , 721 So. 2d 317 (Fla. 1st DCA 1998). ÐAn

existing r ule challenge pursuant to section 120. 56 is directed

to the facial validity of the challenged rule, and not to its

validity as interpreted or applied in specific factual

scenarios.Ñ Hospice of the Fla. Suncoast, Inc. v.

Ag . for Health C are Admin. , Case No. 15 - 3656RX, at FO at 54

(Fla. DOAH S ept . 28, 2016), affÓd 203 So. 3d 159 (Oct. 21,

2016).

32 . AHCA argues that the interpretation and application of

the R ule is moot because both Petitioner and AHCA agree that the

R ule does not require general hospitals to submit audited

financial statements .

33 . A Rule challenge is rendered moot when evidence shows

the rule no longer applies to the party initiating the Rule

challenge . See Montgomery v. DepÓt of HRS , 468 So. 2d 1014,

1016 - 17 (Fla. 1st DCA 1985). There is no evidence that the Rule

no longer applies to VRBH . To the contrary, a ruling in the CON

cases held that the Rule applied to general hospital applicants,

like VRBH .

34 . Moreover, AHCAÓs assertion that it and VRBH are in

agreement is not borne out by the pleadings. Petition er

contends that the Rule is not valid because it does not

differentiate between general hospitals and other CON

applicants. Petition at ¶ 14.

35 . Finally, not all parties agree that the Rule does not

apply to general hospitals; at the very least, Interv enor SMH

touts the validity of the Rule and its applicability to general

h ospital applicants , particularly VRBH .

Standing

36 . Standing in r ule challenge proceedings is governed by

section 120.56(1), which provides that "[a]ny person

substantially affected by a rule or a proposed rule may seek an

administrative determination of the invalidity of the rule on

the ground that the rule is an invalid exercise of delegated

legislati ve authority." In order to establish standing under

the Ðsubstantially affectedÑ test in a r ule challenge

proceeding, the petitioner must show: (1) that the rule or

policy will result in a real or immediate injury in fact; and

(2) that the alleged interest is within the zone of interest to

be protected or regulated. Of f. of Ins. Reg. v. Secure

Enterprises, LLC , 124 So. 3d 332, 336 (Fla. 1st DCA 2013),

(citing Jacoby v. Fla. Bd. of Med. , 917 So. 2d 358, 360 (Fla.

1st DCA 2005)). To satisfy the sufficiently real and immediate

injury in fact element, an injury must not be based on pure

speculation or conjecture. Id. (citing Lanoue v . Fla. DepÓt of

Law Enf. , 751 So. 2d 94, 97 (Fla. 1st DCA 1999)).

37 . V RBH filed this Rule challenge to defend its general

hospital CON application from attack by SMH , based upon an

invalid rule that exceeds AHCAÓs delegated l egislative

authority. As such, VR BH Ós substantial interests are affected.

38 . Furthermore, VR BH has demonstrated that it is within

the zone of interest being protected or regulated, for the

purpo se of esta blishing standing to challenge r ule 59C - 1.008

r elating to CON regulation. The challenged Rule potentially

affects V RBH Ós ability to obtain approval of its CON

application.

39 . Finally, VR BH has demonstrated that the potential

injury to VR BH ( i.e. , denial of its CON application) is real,

and not based on pure speculation or conjecture.

40 . VR BH has demonstrated that it has standing to

challenge the validity of r ule 59C - 1.008.

41 . Additionally, in the context of th is consolidated CON

applicati on and Rule challenge proceeding, the undersigned

previously addressed the issue of VRBHÓs standing and the

mootness argument raised by AHCA :

Standing

Substantially Affected

It is sufficient u nder case law that a

petitioner Ðcould be substantially affected

or could reasonably be substantially

affected by a[n] [adopted] rule.Ñ

Interblock v. DBPR , Case No. 11 - 1075RX (Fla.

DOAH Apr. 7, 2011). Venice Regional

satisfies this requirement because Venice

Regional could be substantially affected by

rule 59 C - 1.008(4)(c) to the extent that the

Rule is interpreted and relied upon by the

undersigned to require a general hospital

CON application to include an audited

financial statement.

Case law further provides that in order for

a petitioner to show that it is

Ðsubstantially affectedÑ by a rule, Ðthe

petitioner must [also] establish:

(1) a real and sufficiently immediate

injury in fact; and

(2) Òthat the alleged interest is arguably

within the zone of interest to be protected

or regulated.ÓÑ

Lanoue v. Fla. DepÓt of Law Enf. , 751 So. 2d

94, 96 (Fla. 1st DCA 1999) (referring to

Ward v. Bd. of Trs. of the Int. Impust

Fund , 651 So. 2d 1236, 1237 (Fla. 4th DCA

1995), which is quoting All Risk Corp. of

Fla. v. State, Dep't of Labor & Emp. Sec. ,

413 So . 2d 1200, 1202 (Fla. 1st DCA 1982));

see Cole Vision Corp. v. DepÓt of Bus. &

ProfÓl Reg. , 688 So. 2d 404, 407 (Fla. 1st

DCA 1997).

Injury

A real and sufficiently immediate injury in

fact requires that the Ðthe person

challenging the validity of an adopted rule

must show a direct injury in fact of

Òsufficient immediacy and realityÓÑ to the

petitioner; the injury may not be Ðpurely

speculative and conjectural.Ñ Fla. Bd. of

Optometry v. Fla. Soc. of Ophthalmology ,

538 So. 2d 878, 881 (Fla. 1st DCA 1988)

(referring to Fla. DepÓt of Offender Rehab.

v. Jerry , 353 So. 2d 1230 (Fla. 1st DCA

1978)). However, ÐinjuryÑ Ðdoes not require

that a challen ger to a rule wait until the

injury occurs to institute a rule -

challenge.Ñ Juan Cuellar v. DepÓt of Bus. &

ProfÓl Reg. , Case No. 07 - 5767RX (Fla. DOAH

Feb. 26, 2008). Instead, potential injury

is sufficient. Id.

Here, it is reasonable to conclude that

V enice Regional faces a sufficient potential

injury since there are multiple challenges

filed to the preliminary approval of Venice

RegionalÓs application, and the

determination of the filing requirements for

a CON, and the outcomes of these petitions

may n egatively affect Venice Regional in

curr ent and future CON proceedings. Stated

succinctly, if the undersigned concludes

that the RuleÓs application content

requirements for a general hospital include

Ðan audited financial statement of the

applicant or the applicantÓs parent

corporation if the applicantÓs audited

financial statements do not exist,Ñ it may

well be established at hearing that VeniceÓs

application fails to satisfy that

requirement, potentially resulting in denial

of the application. Such an o utcome would

clearly affect VeniceÓs substantial

interests.

* * *

Mootness

The interpretation of the challenged Rule

urged by both the Agency and Venice Regional

is contradictory to the above - referenced

Order denying Venice RegionalÓs motion in

limine, where the undersigned found that by

the express terms, the requirements of rule

59C - 1.008(4)(c) are applicable to Venice

RegionalÓs general hospital CON application,

and, that the extent to which Venice

RegionalÓs application complied with the

requirements is a relevant inquiry in Case

No. 17 - 0556CON. However, an interpretation

of the Rule has not been adjudicated by the

undersigned in the instant Rule challenge

proceeding; and, since there remains varying

interpretations of the Rule in this

proceeding, th e matter is not moot.

Conclusion

Venice Regional filed the petition for the

instant Rule challenge proceeding, whi ch is

guided by section 120.56. Venice Regional

complied with the requirements of this

statute by stating facts sufficient to show

that it is substantially affected by the

AgencyÓs adopted Rule, rule 59C - 1.008(4)(c).

Thus, Venice Regional has standing in this

proceeding. The question brought by Venice

RegionalÓs petition, which pertains to the

correct interpretation of the challenged

Rule, is not moot because the interpretation

of this Rule has not been formally

adjudicated by the undersigned in this

proceeding.

(Order Denying Motion to Dismiss, Granting Motion to

Consolidate, and Granting Motion to Amend Answer , June 21,

2017) .

Invalidity of Rule 59C - 1.008(4)

42 . Section 120.52 defines an Ðinvalid exercise of

delegated legislative authority Ñ as:

(8) Ð Invalid exercise of delegated

legislative authorityÑ means action that

goes beyond the powers, functions, and

duties delegated by the Legisl ature. A

proposed or existing rule is an invalid

exercise of delegated legislative authority

if any one of the following applies:

(a) The agency has materially failed to

follow the applicable rulemaking procedures

or requirements set forth in this chapter;

(b) The agency has exceeded its grant of

rulemaking authority, citation to which is

required by s. 120.54(3)(a)1.;

(c) The rule enlarges, modifies, or

contravenes the specific provisions of law

implemented, citation to which is required

by s. 120.54(3)(a)1.;

(d) The rule is vague, fails to establish

adequate standards for agency decisions, or

vests unbridled discretion in the agency;

(e) The rule is arbitrary or capricious. A

rule is arbitrary if it is not supported by

logic or the necessa ry facts; a rule is

capricious if it is adopted without thought

or reason or is irrational; or

(f) The rule imposes regulatory costs on

the regulated person, county, or city which

could be reduced by the adoption of less

costly alternatives that substant ially

accomplish the statutory objectives.

43 . As noted above, the challenged language of r ule 59C -

1.008(4) is directly contrary to s ection 408.037(2), which

clearly and unequivocally Ðexcepts Ñ general hospital CON

applications from the audited financial statement requirement.

However, if the challenged Rule language is stricken,

specifically section 1.008(4)(c), it does no harm to AHCAÓs

interpretation, established practice, and application o f the

requirement that CON applications for projects Ðexcept for a

general hospitalÑ must include an audited financial statement.

The Rule without the challenged provision would simply state

that the statutory content requirements must be followed. The

c hallenged language set forth at section 1.008(4)(c) is ,

therefore , stricken as an invalid exercise of delegated

l egislative authority.

44 . Section 120.52(8) also contains what is referred to as

a "flush - left" provision that restricts the scope of agency

r ulemaking authority. This flush - left paragraph states:

A grant of rulemaking authority is necessary

but not sufficient to allow an agency to

adopt a rule; a specific law to be

implemented is also required. An agency may

adopt only rules that implement or interpret

the specific powers and duties granted by

the enabling statute. No agency shall have

authority to adopt a rule only because it is

reasonably related to the purpose of the

enabling legislation and is not arbitrary

and capricious or is within the agencyÓs

class of powers and duties, nor shall an

agency have the authority to implement

statutory provisions setting forth general

legislative intent or policy. Statutory

language granting rulemaking authority or

generally describing the powers and

func tions of an agency shall be construed to

extend no further than implementing or

interpreting the specific powers and duties

conferred by the enabling statute.

45 . I n Board of Trustees of the Internal Improvement Trust

Fund v. Day Cruise Association, Inc. , 794 So. 2d 696, 700 (Fla.

1st DCA 2001) , the Court observed :

[A]gencies have rulemaking authority only

where the Legislature has enacted a specific

statute, and authorized the agency to

implement it, and then only if the . . .

rule implements or interprets specific

powers and duties, as opposed to improvising

in an area that can be said to fall only

generally within some class of powers or

duties the Legislature has conferred on the

agency.

46 . Each rule must include a citation "to the grant of

rulemaking authority pursuant to which the rule is adopted , " as

well as a citation "to the section or subsection of the Florida

Statutes or the Laws of Florida being implemented or

interpreted." §§ 120.54(3)(a)1. and 120.52(8)(b), (8)(c), Fla.

Stat. ÐAf ter adoption of a rule, the [agency] may not rely on

statutory provisions not cited in the proposed rule as statutory

authority.Ñ DepÓt of Child. & Fam. Serv s . v. I.B . , 891 So. 2d

1168, 1172 (Fla. 1st DCA 2005) (quoting Fla. League of Cities v.

Dep't of Ins. , 540 So. 2d 850, 865 (Fla. 1st DCA 1989)).

47 . In this cas e, r ule 59C - 1.008(4) is outside the

rulemaking authority granted to AHCA by the Legislature.

Although section 408.034(8) states that AHCA may "adopt rules

necessary to implement" the CON law, this general grant of

rulemaking authority "is not sufficient to allow [AHCA] to

adopt" r ule 59C - 1.008(4) as fully applicable to all CON

applications rather than differentiating between the sections

that are applicable to general hospital CON applicat ions and

other non - general hospital CON applications, as set forth in

both section 408.035(2) and section 408.037(2).

48 . The flush - left paragraph in section 120.52(8)

requires, Ða close examination of the statutes cited by the

agency as authority for th e rule at issue to determine whether

those statutes explicitly grant the agency authority to adopt

the rule.Ñ United Faculty of Fla. v. Fl a . State Bd. of Educ. ,

157 So. 3d 514, 517 (Fla. 1st DCA 2015). Therefore, to be

valid, rule 59C - 1.008(4) must "implement or interpret the

specific powers and duties granted by the enabling statute."

Id. ; see § 120.52(9), Fla. Stat.

49 . The "law implemented" section at the end of rule 59C -

1.008 identifies multiple statutes as the "law implemented" by

that r ule, including sections 408.033, 408.034, 308.036,

408.037, 408.039 and 408.042. See § 120.52(9) (defining the

"law implemented" as "the language of the enabling statute being

carried out or interpreted by an agency through rulemaking").

50 . However, a review of the implemented statutes,

specifically section 408.037, confirms that none of the specific

powers and duties conveyed to AHCA by this statute are

implemented by rule 59C - 1.008(4)(c) that, as written , require

general hospital CON applic ants to provide audited financial

statements .

51 . Section 408.037 does not give AHCA an express power or

duty to require general hospital applicants to provide audited

financial statements in the CON application.

52 . Rule 59C - 1.008(4) (c) violates the re quireme nts of

section 120.52(8) (c) , as it clearly Ðenlarges, modifies, or

contravenes the specific provisions of law implemented.Ñ As

su ch, r ule 59C - 1.008(4) (c) is an invalid exercise of AHCAÓs

delegated l egislative authority.

ORDER

Based on the foregoing Findings of Fact and Conclusions of

Law, it is

ORDERED that Florida Administrative Code Rule 59C -

1.008(4) (c) is invalid.

DONE AND ORDERED this 8th day of May , 2018 , in Tallahassee,

Leon County, Florida.

S

W. DAVID WATKINS

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399 - 3060

(850) 488 - 9675

Fax Filing (850) 921 - 6847

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 8th day of May , 2018 .

ENDNOTES

1/ Statutory references herein are to the 2017 version of the

Florida Statutes.

2/ In 2012, the Legislature revised it to allow the submission

of an audited financial statement of the applicantÓs parent

corporation if audited financial statements of the applicant do

not exist. Ch. 2012 - 160, § 42 , Laws of Fla.

COPIES FURNISHED :

Geoffrey D. Smith, Esquire

Susan C. Smith, Esquire

Smith & Associates

3301 Thomasville Road , Suite 201

Tallahassee, Florida 32308

(eServed)

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Tallahassee, Florida 32301

(eServed)

Richard Joseph Saliba, Esquire

Kevin Michael Marker, Esquire

Lindsey L. Miller - Hailey, Esquire

Agency for Health Care Administration

Fort Knox Building III, Mail Stop 7

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Stefan Grow, General Counsel

Agency for Health Care Administration

Mail Stop 3

2727 Mahan Drive

Tallahassee, Florida 32308

(eServed)

Justin Senior, Secretary

Agency for Health Care Administration

Mail Stop 1

2727 Mahan Drive

Tallahassee, Florida 32308

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Agency for Health Care Administration

Mail Stop 3

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Thomas M. Hoeler, Esquire

Agency for Health Care Administration

Mail Stop 3

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Tallahassee, Florida 32308

(eServed)

Richard J. Shoop, Agency Clerk

Agency for Health Care Administration

2727 Mahan Drive, Mail Stop 3

Tallahassee, Florida 32308

(eServed)

Ernest Reddick, Program Administrator

Anya Grosenbaugh

Florida Administr ative Code & Register

Department of State

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Tallahassee, Florida 32399 - 0250

(eServed)

Ken Plante, Coo rdinator

Joint Administrative Procedures Committee

Room 680, Pepper Building

111 West Madison Street

Tallahassee, Florida 32399 - 1400

(eServed)

NOTICE OF RIGHT TO JUDICIAL REVIEW

A party who is adversely affected by this Final Order is

entitled to judicial review pursuant to s ection 120.68, Florida

Statutes. Review proceedings are governed by the Florida Rules

of Appellate Procedure. Such proceedings are commenced by

filing one copy of a Notice of Administrative Appeal with the

agency clerk of the Division of Administrative Hearings and a

second copy, accompanied by filing fees prescribed by law, with

the District Court of Appeal, First District, or with the

District Court of Appeal in the appellate district where the

party resides. The Notice of Administrative Appeal must be

filed within 30 days of rendition of the order to be reviewed.