18-000075CON
Florida Hospital Waterman, Inc., D/B/A Florida Hospital Waterman vs.
Munroe Hma Hospital, Llc And Marion Community Hospital, Inc.
Status: Closed
Recommended Order on Wednesday, February 6, 2019.
Recommended Order on Wednesday, February 6, 2019.
1S TATE OF FLORIDA
5DIVISION OF ADMINISTRATIVE HEARINGS
9MARION COMMUNITY HOSPITAL, INC.,
13d/b/a WEST MARION COMMUNITY
17HOSPITAL AND OCALA REGIONAL
21MEDICAL CENTER,
23Petitioners,
24vs. Case Nos. 18 - 0068CON
3018 - 0075CON
33AGENCY FOR HEALTH CARE
37ADMINISTRATION AND FLORIDA
40HOSPITAL WATERMAN, I NC., d/b/a
45FLORIDA HOSPITAL WATERMAN,
48Respondents.
49_______________________________/
50RECOMMENDED ORDER
52Administrative Law Judge John D. C. Newton, II, of the
62Division of Administrative Hearings con ducted the final h earing
72in this cause on June 18 through 22 and 25, 2018, in Tallahassee,
85Florida.
86APPEARANCES
87For Petitioner s Marion Community Hospital, Inc. , d/b/a West
96Marion Community Hospital and Oc ala Regional Medical
104Center
105Craig D. Miller, Esquire
109J. Stephen Menton, Esquire
113Rutledge Ecenia , P.A.
116119 South Monroe Street, Suite 202
122Tallahassee, Florida 32301
125For Respondent Agency for Health Care Admi nistration
133Richard Joseph Saliba, Esquire
137Lindsey L. Miller - Hailey, Esquire
143Agency for Health Care Administration
148Mail Stop 7
1512727 Mahan Drive
154Tallahasse e, Florida 32308
158For Respondent Florida Hospital Waterman , Inc., d/b/a
165Florida Hospital Waterman
168Stephen K. Boone, Esquire
172Boone , Boone , Boone , and Koda , P.A.
1781001 Avenida D el Circo
183Post Office Box 1596
187Venice, Florida 34284
190Mia L. McKown, Esquire
194Holland & Knight , LLP
198315 South Calhoun Street, Suite 600
204Tallahassee, Florida 32301
207STATEMENT OF T HE ISSUE S
213A. Should the Agency for Health Care Administration
221(Agency) approve Certificate of Need (CON) Application No. 10499
230of Marion Community Hospital, Inc. (Marion Community) , d/b/a West
239Marion Community Hospital (West Marion), to add 12 comprehensi ve
249medical rehabilitation (CMR) beds to its facility?
256B. Should the Agency approve CON Application No. 10496 of
266Florida Hospital Waterman , Inc. (Waterman) , to add 12 CMR beds to
277its facility?
279PRELIMINARY STATEMENT
281West Marion and Waterman are acute care h ospitals located in
292Agency Health Service Planning District 3. For the applicable
301planning horizon, the Agency calculated a need for 12 new CMR
312beds in District 3. West Marion and Waterman each would like to
324add 12 CMR beds to their facility. They do no t oppose each other
338adding beds. They agree that Ðnot normal circumstancesÑ
346establish a need for at least 24 new CMR beds in District 3.
359Each maintains that if only one may add CMR beds, it is the one.
373The Agency approved WatermanÓs application and deni ed West
382MarionÓs application . This proceeding followed.
388At the hearing, West Marion presented the testimony of Chad
398Christianson, Carrie Garay - Quirantes, Jeff Nasman, Gene Nelson,
407and Katherine M. T. Platt. West Marion Exhibits 1 through 8, 12,
41914, 17, 1 8, and 20 through 23 were accepted into evidence. After
432the hearing, West Marion submitted the deposition transcript of
441Cory Hewitt, which was admitted in lieu of live testimony as West
453Marion Exhibit 35. On August 27, 2018, West Marion filed the
464deposit ion transcript of James Duke, which was accepted as West
475Marion Exhibit 25. The record was closed at this point.
485Waterman presented the testimony of Abel Biri, Julian
493Coomes, Tracey Estok, Mitchell Freed, David Levitt, and Michelle
502Maes. Waterman Exhibit s 1, 3 through 9, and 11 were accepted
514into evidence.
516The Agency presented the test imony of Marisol Fitch. Agency
526Exhibits 1 and 2 were admitted into evidence.
534A T ranscript of the hearing was filed. The parties obtained
545two extensions of the date for f iling proposed recommended
555orders. West Marion and Waterman timely filed proposed
563recommended orders. Waterman also filed a Memorandum of Law.
572The Agency timely filed a Memorandum of Law. The undersigned has
583considered the partiesÓ submissions in prepa ration of this
592Recommended Order.
594FINDING S OF FACT
598Stipulations
5991. There is a published need for 12 CMR beds in District 3.
6122. Waterman is an existing licensed hospital that currently
621operates a 269 - bed facility in Service District 3,
631Sub - District 7, La ke County.
6383. Ocala Regional Medical Center (Ocala Regional) is an
647existing licensed hospital that operates a 222 - bed acute care
658facility in S ervice District 3, Sub - District 4, Marion County.
6704. West Marion is an existing licensed hospital that
679currently operates a 138 - bed facility in District 3, Sub - District
6924, Marion County.
6955. Marion Community Hospital, Inc. , d/b/a Ocala Regional
703Medical Center , is a verified Level II trauma center.
7126. West Marion and Waterman satisfy the CON review criteria
722regardin g the costs and methods of the proposed construction,
732including the costs and methods of energy provision and the
742availability of alternative, less costly, or more effective
750methods of construction. § 408.035(1)(h), Fla . Stat . (2018). 1/
7617. Schedules 1 th rough 10 of each hospitalÓs application
771are reasonable.
7738. West Marion and Waterman satisfy the CON application
782review criteria regarding the immediate and long - term financial
792feasibility of their proposals. § 408.035( 1 )(f), Fla. Stat.
802Parties
803The Age ncy
8069. The Agency is the state agency charged with administering
816the CON program. Section 408.034(1) , Florida Statutes authorizes
824the Agency to evaluate CON applications.
830West Marion
83210. Marion Community owns West Marion and Ocala Regional.
841Both are a cute care hospitals. Marion Community proposes to
851establish a 12 - bed CMR unit at its W e st Marion campus. This is a
868new service. West Marion and Ocala Regional operate using one tax
879ID number and one Medicare billing number. One medical executive
889commit tee governs the medical staff for both facilities. They
899have the same Chief Executive Officer and Chief Financial Officer.
909They have different physical facilities and locations. These
917facilities, along with Summerfield freestanding emergency
923department, operate as the Ocala Health System (Ocala Health).
93211. Ocala Regional is located in Ocala, Marion County,
941Florida. West Marion is also located in Ocala. West MarionÓs
951primary service area is Marion County (Sub - District 4).
96112. Ocala Health is a fast g rowing health system. It serves
973a large geriatric (65 and older) population. West Marion and
983Ocala Regional provide acute health care services to patients who
993need CMR services.
99613. Ocala Regional treats a more acutely ill patient
1005population. That pop ulation includes patients recovering from
1013bilateral joint replacements (replaci ng both knees at once) ;
1022patients recovering from trauma injuries, especially severe brain
1030and spinal cord injuries; and patients recovering from strokes.
103914. Marion Community p lans to locate the CMR beds at West
1051Marion. West Marion is located on 50 acres that provide plenty of
1063space for the CMR unit and room for future growth. West Marion
1075should complete its most recent expansion by March 2019,
1084increasing its inventory of acut e care beds to 174.
109415. West Marion plans to contract with Strive Physical
1103Therapy Centers (Strive) . Strive is the contracted p hysical
1113therapy, occupational therapy , and speech therapy provider for the
1122Ocala Health System, providing outpatient and inpati ent services.
1131It is a competent professional health care provider.
11391 6 . West Marion operates a very busy orthopedic joint
1150replacement program that has become a destination center for total
1160joint replacement patients. The joint replacements conducted at
1168West Marion include many of the most complex types, including
1178bilateral replacements , revision replacements of joint
1184replacements, surgeries for severely overweight patients, and
1191surgeries for patients over the age of 85.
11991 7 . Many of these patients requi re intensive and prolonged
1211rehabilitation. CMR services would benefit them greatly.
12181 8 . This category of West MarionÓs patients experiences
1228problems accessing CMR services.
12321 9 . Ocala Regional recently began a $64 million expansion
1243project. It includes the addition of 12 emergency department
1252beds, 34 additional beds at the hospital , two additional operating
1262rooms , and the infrastructure necessary for comprehensive stroke
1270center certification.
127220 . Ocala Regional operates a Level II t rauma c enter.
1284Trauma service is a regional program. T he sweep of a 40 - mile
1298radius around the hospital circumscribe s Ocala Regional's trauma
1307service area . The area includes Marion, Citrus, and Hernando
1317Counties. It contains approximately one million people.
13242 1 . Ocala Regi onalÓs trauma center is the fourth busiest
1336trauma center in Florida. Since opening in December 2012, the
1346trauma center has experienced a yearly growth rate of 11 percent.
1357This is greater growth than other Florida trauma centers, likely
1367the result of grow th in the size of the areaÓs geriatric
1379population. Members of that population are more prone to serious
1389injury in accidents. Ocala Regional Ó s Trauma Center treats
1399approximately 3,500 trauma patients a year.
14062 2 . Ocala RegionalÓs high acuity trauma progra m cares for
1418patients with traumatic brain and spinal cord injuries. Ocala
1427Regional has a highly trained staff, including seven trauma
1436critical care physicians and three neurosurgeons, specializing in
1444treatment of traumatic brain injuries and severe spinal cord
1453injuries.
14542 3 . Ocala Regional recently expanded its facility to include
1465a state of the art intensive care unit that will increase the
1477number of high acuity patients in need of CMR services.
14872 4 . Sixty - five percent of Ocala Regional Ó s trauma patient s
1502come from Marion County. The rest come in roughly equal numbers
1513from Lake, Sumter, and Citrus C ounties. Ocala Regional is also a
1525receiving facility for trauma patients from The Villages Regional
1534Hospital in Sumter County, and for advanced trauma patien ts of
1545another area hospital, Munroe HMA Hospital, LLC , d/b/a Munr o e
1556Regional Medical Center . 2/
156125 . Need for CMR services correlates naturally with the
1571provision of trauma services because trauma patients often require
1580intensive and prolonged rehabilitatio n therapies to return to
1589normal daily activities. These patients can benefit greatly from
1598the intensive rehabilitation services offered through CMR units.
16062 6 . Ocala Regional also operates a certified primary stroke
1617center. It currently provides all trea tment modalities, with the
1627exception of interventional neurology. Ocala Health serves a high
1636volume of stroke patients, in part due to the large geriatric
1647population that it serves. As with trauma services, the elderly
1657are more likely to need CMR service s than the general population.
166927 . Stroke patients are the biggest driver of CMR admissions
1680because a stroke patient requires the intensive, multi - discipline
1690therapies that CMR units provide. West Marion operates a primary
1700stroke center. Patients of thi s center also experience problems
1710accessing CMR services.
17132 8 . Ocala Regional is in the final stages of obtaining
1725approval to operate as a comprehensive stroke center. This
1734provides care for patients suffering large vessel strokes, the
1743most serious sort.
17462 9 . When a stroke patient meets the criteria for large -
1759vessel disease, a primary stroke center is not as good a treatment
1771option as a comprehensive stroke center, which is able to provide
1782necessary interventional neurology services.
178630 . Comprehensive str oke patients are a primary driver for
1797the need for inpatient rehabilitation services . CMR services
1806benefit these patients by addressing immediate post - stroke
1815deficits such as aphasia, hemiparesis (weakness on one side of the
1826body), and cortical blindness. These patients will immediately
1834require the largest amount of CMR services.
18413 1 . Certification of Ocala Regional as a comprehensive
1851stroke program will enable Ocala Regional to serve as the
1861comprehensive stroke program for Marion, Lake, Sumter , and Citru s
1871Counties, an area with a population of approximately one million
1881people. This will promptly drive an increased need for CMR
1891services not accounted for by the Agency rule. The Emergency
1901Medical Treatment and Labor Act requires that large vessel stroke
1911p atients be transported to a comprehensive stroke center.
19203 2 . T he comprehensive stroke programs closest to Marion
1931County are located in Tampa, Gainesville , and North Florida. 3/
1941Once certified, Ocala Health will be the first and only
1951comprehensive stroke center in Ocala. The number of severe stroke
1961patients treated at Ocala Regional will rise and correspondingly
1970immediately increase the need for CMR beds in Marion County.
19803 3 . The geriatric population is growing in District 3, in
1992general, and in Marion County specifically. This area also
2001experiences a s easonal influx of elderly when ÐsnowbirdsÑ come to
2012Florida during the winter. The geriatric population greatly
2020benefits from access to CMR services. It also generates an
2030increased need for CMR services.
20353 4 . Access to CMR beds is a consideration for certification
2047as a trauma center and certification as a comprehensive stroke
2057program. This demonstrates a correlation between these programs
2065and a more robust need for CMR services. Ocala Health Ó s
2077significa nt programs in these vital service areas are a strong
2088consideration in favor of approving CMR services at West Marion.
2098The new CMR beds will ensure access to needed health care services
2110in the community.
21133 5 . Ocala Regional is also developing a graduate m edical
2125education (GME) program for various disciplines. A GME program
2134typically increases the sub - specialties available at a hospital.
2144This in turn facilitates treatment of more complex cases and
2154patients more likely to need CMR services.
21613 6 . Establishm ent of the GME program is helping transform
2173Ocala Regional into a tertiary facility serving the needs of
2183Marion, Lake, Sumter, and Citrus Counties . The GME program will
2194also improve services for trauma patients, complex cardiology
2202cases, and advanced neur osurgical cases. The corresponding
2210increase in patient acuity will bolster the need for CMR beds in a
2223manner which the need rule cannot anticipate.
22303 7 . These patients will benefit greatly from sufficient and
2241timely access to CMR beds and the continuity o f care that
2253accompanies location of a CMR unit in conjunction with an acute
2264care hospital.
2266Waterman
22673 8 . Waterman is a not - for - profit 269 Î bed acute care
2283hospital located in Tavares, Lake County, Florida, in the
2292southeastern corner of District 3. It ser ves residents of north,
2303central, and west Lake County. Waterman proposes to establish a
231312 - bed CMR unit at its Tavares facility. Waterman accepts all
2325patients, regardless of their ability to pay.
23323 9 . Waterman is part of the Florida Hospital System, whic h
2345has facilities on 23 campuses and serves communities throughout
2354Florida. Waterman is also part of the Adventist Health System.
2364The system owns a broad variety of health care facilities
2374including 42 hospitals in ten states.
238040 . Waterman is opening a 60 - bed skilled nursing facility on
2393its campus. WatermanÓs new skilled nursing facility will provide
2402some rehabilitation services to patients discharged from the
2410hospital. The services, however, will not be an adequate
2419substitute for the more intense CMR services. This is also true
2430of home health services.
24344 1 . Waterman is a tertiary level hospital. It serves a
2446large, fast - growing area. It is the busiest hospital in Lake
2458County as measured by emergency visits and discharges. Waterman
2467offers a wide arra y of high quality medical and surgical services.
2479They include an accredited cancer institute, open - heart surgery,
2489knee and hip replacements, extracorporeal membrane oxygenation,
2496and 24 - hour advanced emergency services. Waterman is also a
2507primary stroke c enter. It is not currently, and is not in the
2520process of becoming, a certified comprehensive stroke center.
2528Waterman is also not a designated trauma center.
25364 2 . Waterman operates a robust outpatient rehabilitation
2545unit, the Florida Hospital Waterman Reh abilitation Institute
2553(Institute). The Institute provides a wide variety of treatments
2562and unique specialty care such as physical therapy, hand therapy,
2572speech therapy, language therapy, pelvic rehabilitation,
2578neurological therapy, amputee rehabilitation, orthopedics , and
2584sports medicine. Waterman CMR patients will benefit from
2592WatermanÓs use of the skills, caregivers, and experience of the
2602Institute in operating its CMR unit. The Florida Hospital system
2612operates several successful CMR programs. Waterma n Ós CMR services
2622will have the benefit of assistance from the administrators and
2632clinicians from these sister facilities as it develops,
2640implements, and operates its CMR unit. These resources require
2649finding that Waterman will more quickly bring enhanced quality of
2659care to the District.
26634 3 . Waterman also operates a Home Care Agency. The agency
2675has provided home health care -- including physical, occupational,
2684and speech therapy services -- to residents of Lake County and the
2696surrounding areas since 197 7.
270144 . Waterman has several expansion projects underway. A
2710related organization is building a 120 - bed nursing home on the
2722Waterman campus. Waterman is also completing a $75 million
2731capital improvement project that will increase the size of its
2741emergency department and will add a patient tower for pediatrics
2751and womenÓs services. Waterman plans to house the proposed CMR
2761unit in the tower.
27654 5 . West Marion and Waterman are well - staffed , high - quality
2779hospitals, affiliated with high - quality health care syst ems. They
2790each provide their patients good care and are fully capable of
2801establishing and operating the CMR units for which they seek
2811certificate of need approval.
2815CON Regulation and Need
28194 6 . Every six months the Agency publishes projected numeric
2830need for CMR beds in each health care planning district. Florida
2841Administrative Code Rule 59C - 1.039 regulates establishment of new
2851CMR services and the addition or construction of new CMR beds.
2862The AgencyÓs rule provides that a determination of need for CMR
2873beds Ðshall not normally be madeÑ unless the ruleÓs numeric
2883methodology calculates one.
28864 7 . The rule establishes a simple formula for calculating
2897CMR bed need. The formula calculates the current utilization
2906ratio for CMR services in the district by div iding the number of
2919patient days reported for inpatient CMR beds and dividing it by
2930the district population for the same period. It then multiplies
2940the ratio times the projected population for the planning horizon,
2950five years into the future. The rule di vides that product by 365
2963times 85 percent. The rule specifies that 85 percent Ðequals the
2974desired average annual occupancy rate for [CMR] beds in the
2984district.Ñ
29854 8 . This operation calculates the gross number of beds
2996needed for the district. T he rule su btracts the licensed and
3008approved CMR beds in the district from that number . The resulting
3020number is the net number of beds needed. The rule does not
3032account for markets in which patients needing CMR services receive
3042similar , but not equivalent, less int ense services from providers
3052such as home health agencies, skilled nursing homes, or acute care
3063hospitals without designated CMR beds, due to limited access to
3073CMR beds. It also looks back , not forward. The need methodology
3084promotes competition and acces s when the use rate in a service
3096area falls below the statewide average use rate.
31044 9 . The need rule also provides that, regardless of whether
3116the formula shows need, Ðno additional [beds] shall normally be
3126approved unless the average annual occupancy rate of the beds in
3137the district was at least 80 percent for the 12 month period
3149ending six months prior to the beginning date of the quarter of
3161the publication of the Fixed Bed Need Pool.Ñ Fla. Admin. Code R.
317359C - 1.039(5)(d).
317650 . The AgencyÓs rule calculat ed a need for 12 new CMR beds
3190in District 3 for the January 2023 planning horizon. District 3
3201includes Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist,
3208Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,
3216Suwannee , and Union C ounties. The Agency had not published a need
3228for CMR beds in District 3 for many years. This is because
3240changes in CON regulation allowed existing providers to add beds
3250in ten - bed increments if they met a specific occupancy threshold.
3262In Ocala, HealthSouth Rehab ilitation Hospital (HealthSouth) did
3270this assiduously, effectively stifling what would otherwise have
3278been a natural progression of need pool determinations.
32865 1 . West Marion and Waterman agree that Ðnot normal
3297circumstancesÑ establish a need for at least 12 CMR beds in
3308addition to the 12 generated by the numeric need formula. This is
3320an unusual CON case in this way. There is not a party arguing
3333that either application should be denied or offering evidence to
3343support d enial . This includes the Agency , whi ch offers only
3355technical legal arguments against approving both applications.
3362Effectively , the Agency implicit ly concedes the need for both
3372programs.
337352. The AgencyÓs tacit concession that circumstances are not
3382normal in District 3 manifests in another w ay. T he Agency,
3394without comment or explanation, proposes approving a new 12 - bed
3405CMR unit. This is despite r ule 59C - 1.039(3)(c) , which states, ÐA
3418general hospital providing Comprehensive Medical Rehabilitation
3424Inpatient Services should normally have a min imum of 20
3434C omprehe n sive Medical Rehabilitation Inpatient beds.Ñ The
3443AgencyÓs proposed approval of a 12 - bed CMR unit confirms that
3455something is not normal in District 3 when it comes to CMR
3467services.
34685 3 . Rule 59C - 1.039(5)(f)3. grants priority considerati on to
3480an applicant that is a designated trauma center as defined in
3491Florida Administrative Code Rule 64J - 2.011. West Marion claims
3501entitlement to a preference for trauma centers based upon the fact
3512that all of the Ocala Health system facilities operate un der the
3524same license. The facts do not support the argument. Although
3534Marion CommunityÓs hospital license is for all Marion Community
3543facilities, the trauma designation is for the Ocala Regional
3552facility , not the West Marion facility .
35595 4 . A review of th e trauma center rule 64J - 2.011, including
3574an application that it incorporates by reference , makes clear that
3584the trauma center designation is for a facility not a system. For
3596instance, the Level II Trauma Center Application Manual (DH Form
36062043 - A, January 2010) requires the following facility - specific
3617information: Recovery/Post - Anesthesia Care Unit; Trauma
3624Resuscitation Area; helicopter landing site; an immediately
3631available adequately staffed operating room for trauma patients 24
3640hours a day; a second ad equately staffed operation room available
3651within 30 minutes after the primary operating room is occupied; a
3662post - anesthesia recovery area; airway control and ventilation
3671equipment in the operating room; invasive hemodynamic monitoring
3679equipment; and a frac ture table. It is inconceivable that a
3690trauma center could satisfy these requirements by having some of
3700the facilities, such as the primary operating room, in one
3710location and other facilities, such as the backup operating room
3720or helicopter landing site, in another.
37265 5 . This does not, however, mean that the presence of a
3739trauma center in the district is not relevant to considering the
3750need for CMRauma center patients have a greater and more
3760frequent need for CMR services than general acute care pati ents.
3771CON Applications
37735 6 . The Agency maintains that the applications did not
3784present a Ðnot normal circumstancesÑ theory and that, therefore,
3793the parties cannot advance the theory at this point. The
3803applications, however, did.
38065 7 . The applications of W est Marion and Waterman sought
3818approval relying upon arguments specific to their service areas
3827and facilities , as well as relying on the calculated need. The
3838arguments amount to claims that their projects should be approved
3848because of Ðnot normal circumst ances.Ñ In the context of the
3859application review and of this proceeding, each applicant had to
3869advance two theories. The first is why it should be selected to
3881satisfy the numeric need. The second is why, regardless of
3891calculated need, Ðnot normal circum stancesÑ call for approval of
3901the applicantÓs proposal. The facts and reasoning supporting each
3910argument are congruent if not identical. Consequently, there was
3919no need to label application assertions in the applications or
3929evidence at hearing as applyin g to one theory or the other.
39415 8 . West MarionÓs CON application sought to fill the
395212 - bed numeric need. It also relied upon Ðnot normal
3963circumstances Ñ for approval of its proposed 12 - bed unit.
39745 9 . West MarionÓs application discusses the unavailabil ity
3984of CMR beds at HealthSouth, the countyÓs only CMR provider. It
3995reviews the fact that HealthSouth has operated at or near capacity
4006since opening, despite two ten - bed additions. Then West Marion
4017concludes, on page 18 of the application, ÐThis chronic
4026u navailability of inpatient beds at HealthSouth creates a severe
4036accessibility problem for the growing population of Marion County,
4045and constitutes a not normal circumstance. Ñ (WM Ex. 1, p. 22) 4/
4058(emphasis add ed).
406160 . Another part of West MarionÓs appli cation discussing the
4072unavailability of beds at HealthSouth makes a similar assertion.
4081Page 52 of West MarionÓs application (WM Ex. 1, p. 55) states,
4093ÐThe chronic shortage of CMR beds in Marion County, especially
4103given the location at ORMC of a Level II t rauma center serving the
4117residents of TSA 6 (Marion, Citrus and Hernando counties), is a
4128not normal circumstance. Ñ (emphasis add ed).
413561 . The same page of the application states that the
4146consistently high utilization of HealthSouth creates significant
4153diff iculty obtaining suitable CMR services for patients discharged
4162from Ocala HealthÓs trauma program.
41676 2 . West MarionÓs application repeatedly notes that its
4177approval will not adversely affect existing providers or the
4186proposed Waterman CMR unit.
41906 3 . Wate rmanÓs CON application sought to fill the 12 - bed
4204need calculated by the Agency. It also relied upon Ðnot normal
4215circumstances Ñ for approval of its proposed 12 - bed unit. The
4227statement on page 6 of the application (W H Ex. 1, p. 118) is
4241explicit. Ð[Waterma nÓs] proposal has been developed to respond to
4251the published numerical need for additional CMR services in
4260District 3, as well as health planning factors that exist even in
4272the absence of numerical need. The need for a CMR unit at
4284[Waterman] is based on a lack of accessible CMR services for
4295residents of Lake County that is evidenced by the following
4305facts . Ñ (emphasis add ed) . A list of seven factors follows ,
4318including that the Lake County population aged 65 or older is
4329increasing faster than the d istrictÓ s and the fact that approval
4341of beds for Waterman would not adversely affect existing
4350providers.
43516 4 . Page 30 of WatermanÓs application (W H Ex. 1, p. 142)
4365repeats the assertion of Ðnot normal circumstances.Ñ It states,
4374Ð[Waterman] has developed this pro posal in response to the
4384published need for additional CMR beds in the District, as well as
4396facility and market - specific factors that clearly show the beds
4407should be located within Lake County and at [Waterman]. Ñ
4417(emphasis adde d) . WatermanÓs application continues the theme on
4427page 37 (Waterman Ex. 1, p. 149) asserting, Ðthere is a barrier to
4440accessibility of inpatient rehabilitation services for residents
4447of Lake County and those who are discharged from [Waterman] . Ñ
44596 5 . West Marion committed to a minimum of seven percent of
4472its annual discharges being a combination of Medicaid, Medicaid
4481HMO, and self - pay/other (including charity) patients. This
4490commitment is consistent with its financial projections that show
44998.89 percent of its first - year revenue/charge s attributed to
4510services for that population. It will enhance access to CMR
4520services.
45216 6 . Waterman made no commitment to serve these populations.
4532WatermanÓs first - year financial projections show 5.3 percent of
4542revenue/charges attributed to services for that population.
4549CMR Services and District 3
45546 7 . CMR services are provided to patients discharged from an
4566acute care hospital after treatment for an ailment or event that
4577requires substantial rehabilitation before the patient resumes
4584normal daily activiti es. For example, patients with complex
4593nursing or medical management needs or conditions such as spinal
4603cord injury, amputation, multiple sclerosis, hip fracture, brain
4611injury, and neurological disorders need CMR services. Fla. Admin.
4620Code R. 59C - 1.039(2 )(d). Patients recovering from an acute
4631episode such as a severe trauma injury or stroke and patients
4642recovering from complex orthopedic joint replacement surgeries
4649such as bilateral joint replacements and patients with a high body
4660mass index (BMI) recove ring from joint replacements also need CMR
4671services.
46726 8 . The continuum of care for physical rehabilitation
4682services comprises a range of levels, depending primarily on
4691patient condition/goals, medical management requirements, and the
4698ability to participat e in therapy. Patients can receive physical
4708rehabilitation in an acute rehabilitation unit inside a hospital
4717or freestanding facility (a CMR u nit), a skilled nursing facility,
4728through a home health agency, or in an outpatient setting. CMR
4739units, which ar e at issue in this case, provide the most intense
4752level of rehabilitation.
47556 9 . Determinations of whether a CMR admission is necessary
4766depend on whether the medical record demonstrates a reasonable
4775expectation that certain criteria are met at the time of a dmission
4787to a CMR unit. The criteria include : (1) requiring active and
4799continuing intervention of multiple therapy disciplines ( Physical
4807Therapy, Occupational Therapy, Speech - Language Pathology, or
4815prosthetics/orthotics ) , at least one of which must be PT or OT;
4827(2) requiring an intensive rehabilitation therapy program of three
4836hours of therapy per day at least five days per week; (3) having
4849an ability to actively participate in, and benefit significantly
4858from, an intensive rehabilitation therapy program; (4) requiring
4866supervision by a rehabilitation physician, with face - to - face
4877evaluations at least three days per week; and (5) requiring an
4888intensive and coordinated interdisciplinary team approach to the
4896delivery of rehabilitative care.
490070 . Family support and involvement play a vital part in the
4912rehabilitation process. Family members are also part of the care -
4923giver team. Additionally, positive attitudes and reinforcement
4930from family members can inspire the patient and help her adapt to
4942new physical challe nges or limits. Finally, family members are
4952able to assist staff in motivating the patient and maintaining
4962communication between the patient and the rehabilitation team.
497071 avel distance plays a significant role in an eligible
4980CMR patientÓs decision t o enter a CMR unit. Elderly patients
4991and/or their families often do not choose to travel far from their
5003home even though the patient needs the CMR services, because
5013travel places an unreasonable burden on patient s and their
5023famil ies .
50267 2 . CMR facilities f ocus on speech, physical, and
5037occupational therapies. A CMR facility provides intensive therapy
5045on a frequent, consistent basis. This helps patients recover more
5055quickly than they would in another setting.
50627 3 . The F ederal Center for Medicare and Medic aid Services
5075( Ð CMS Ñ ) establishes the requirements for CMR facilities, which are
5088designated b y CMS as Ð inpat ient rehabilitation facilities.Ñ CMR
5099facilities are also sometimes referred to as acute rehabilitation
5108facilities.
51097 4 . HealthSouth is the only CMR provider in Marion County in
5122District 3. Lake County does not have a CMR provider. There was
5134a CMR unit located at Leesburg Regional Hospital North in Lake
5145County until July 1, 2016. That facility closed. The CMR beds
5156from the Leesburg facility were tr ansferred to The Villages, which
5167is located in Sumter County. The evidence is insufficient to
5177establish the reason for this.
51827 5 . HealthSouth is the closest CMR provider to West Marion
5194and Ocala Health. It is a stand - alone CMR facility in Ocala. The
5208fac ility has been authorized to add ten more beds. The record is
5221silent on when the beds will be added. HealthSouth opened in 2011
5233with 40 beds and has grown to 60 beds in ten - bed increments.
5247Since 2012, HealthSouth has maintained an occupancy rate of
525690 percent or higher. Despite its incremental growth, HealthSouth
5265has not had sufficient available beds to meet the needs of
5276patients from Ocala Health and West Marion or the district in
5287general.
52887 6 . District 3Ós CMR occupancy rate is 86.5 percent. This
5300is the highest rate for any district and is above the 85 percent
5313that Agency rule establishes as the desired occupancy rate.
53227 7 . All clinicians and experts in this case agree that
5334rehabilitation services at skilled nursing facilities, long - term
5343acute care hospitals, and home with home health care are not
5354acceptable alternatives to CMR. They also agree that patient
5363outcomes in those settings are not as good , since th o se settings
5376simply do not provide the same level of care as a CMR unit.
5389Access Problems
53917 8 . There is no legal mandate requiring a licensed facility
5403to accept CMR patients. A CMR facility may refuse any patient
5414that it wishes. This means that HealthSouth can cherry - pick
5425patients based on the most desirable payor source, leaving
5434patients with less desirable payment providers, such as Medicaid,
5443without access to CMR services. HealthSouth has demonstrated a
5452preference for certain pay o rs (including Medicare - eligible
5462patients, patients with commercial insurance including some Blue
5470Cross policies). It typically does not accept Medicaid or charity
5480care patients. Ocala Health providers often do not even try to
5491refer a Medicaid or charity care patient to HealthSouth because,
5501based on experience, staff expects that HealthSouth will not admit
5511those pat ients.
551479 . HealthSouth frequently refuses to accept patients
5522discharged from Ocala Health who qualify for CMR services under
5532the CMS guidelines, including trauma, stroke , and complex
5540orthopedic joint replacement patients. A large number of the
5549patients t hat Ocala Health refer s to HealthSouth each month are
5561not accepted and are not able to receive CMR services that would
5573improve their outcomes.
55768 0 . HealthSouth Ó s admissions practices leave many Ocala
5587Health patients needing CMR services without access to t hem. This
5598vitiates consideration of HealthSouth as a reason to not add CMR
5609beds in Marion County and District 3.
561681 . There is a large unmet need for additional CMR beds to
5629serve Ocala Health p atients and other district residents.
56388 2 . Some patients rejec ted by HealthSouth are admitted to
5650skilled nursing facilities in Marion County. For patients needing
5659CMR services, those facilities, although they provide some
5667rehabilitative care, are not the correct solution. For example,
5676treatment of the large vessel stroke patients, which Ocala
5685Health Ó s comprehensive stroke center will serve, at a skilled
5696nursing facility is not appropriate. Similarly, a skilled nursing
5705facility would not meet the CMR needs other higher acuity
5715patients , like bilateral transplant pati ents, the multidiscipline,
5723intensive three hours a day therapy that a CMR facility provides.
57348 3 . A skilled nursing facility provides rehabilitat ion
5744services for approximately one to one and a half hours daily.
5755This can result in a longer recovery time fo r high acuity
5767patients. A skilled nursing facility is geared more toward
5776patients with a simple hip fracture. Patients with more complex
5786issues like bilateral joint replacements and spinal cord injuries
5795need more.
57978 4 . In a CMR facility, the patient sees a physician every
5810day. In a skilled nursing facility, a patient usually sees a
5821phy sician once a month. A skilled nursing facility is not optimal
5833for higher acuity acute patients. However, due to the utilization
5843and admission practices of HealthSouth, p atients who need CMR
5853services are often treated in skilled nursing facilities. This
5862unusual circumstance causes the CMR need formula to under -
5872calculate District 3Ós need for CMR beds since the se skilled
5883nursing patients are not taken into consideration, w hereas they
5893would be if they were being treated in a CMR unit, as they should
5907be.
59088 5 . HealthSouth admission practices, consistently high
5916occupancy rates, and delays in responding to referrals result in
5926many patients who are ready for discharge with a phys ician order
5938for CMR services, languishing in acute care beds at Ocala Regional
5949or West Marion for longer lengths of stay or forc e the patients to
5963travel to a CMR facility further from the patient's home and
5974support system.
59768 6 . These problems can negativel y affect patient outcomes
5987because the sooner patients star t ambulating and leave an acute
5998care facility, the less chance they have of suffering
6007complications.
60088 7 . When a patient cannot gain admission into a CMR facility
6021and remains in an acute care bed, the patient is not receiving the
6034needed CMR services ordered by the physician. This can cause a
6045decline in their ability to benefit from therapy or an avoidably
6056prolonged recovery.
60588 8 . Because many of District 3 patients are elderly, their
6070stay in a CM R facility, if and when they are admitted, ends up
6084being longer than it would have been if they were more promptly
6096placed.
60978 9 . Younger patients also suffer from the lack of timely
6109access to CMR. For example, a younger patient suffering from
6119paralysis who has to remain in the hospital would benefit from
6130approval of both application s because the patient will receive
6140more therapy and opportunities for family support. While the
6149hospital provides rehabilitative therapies in the acute care
6157hospital setting, th ose services are provided at bedside and are
6168limited in time and intensity compared to what a patient would
6179receive in a CMR unit.
618490 . The difficulty and delays in transferring patients to
6194appropriate rehabilitation facilities cause Ocala Health hospital s
6202to have a length of stay that is greater by a day or a day and a
6219half than other trauma centers.
62249 1 . The lack of availability of access to CMR services and
6237the lack of timely access to CMR services negatively affects the
6248Marion Community hospitals and their patientsÓ access to necessary
6257services. When a patient is ready for discharge but has to remain
6269in an acute care bed due to lack of availability of CMR beds, the
6283availability of an acute care bed for a new acute care patient is
6296reduced. This can r e sult in the hospital going on Ðbypass,Ñ
6309meaning no new patients are taken in through the emergency room.
63209 2 . In District 3 during the 12 - month period ending
6333December 31, 2016, six facilities with 202 licensed CMR beds
6343served the entire district. The f acilities are UF Health Shands
6354Rehab Hospital, Seven Rivers Regional Medical Center (now closed),
6363HealthSouth Rehab ilitation Hospital of Spring Hill, Leesburg
6371Rehabilitation Hospital, The Villages Regional Hospital (The
6378Villages), and the HealthSouth facil ity . The District 3 beds are
6390located in Marion, Sumter, Hernando, and Alachua C ounties. None
6400are in Lake County.
64049 3 . These facilities experienced an 84.15 percent
6413utilization rate. This is only .85 percent less than the AgencyÓs
6424desired annual occupanc y rate and is nearly five percent greater
6435than the 80 - percent occupancy rate the AgencyÓs rule sets as a
6448trigger for approving additional beds. Fla. Admin. Code R. 59C -
64591.039(5)(d). This was the highest CMR occupancy rate in the
6469state. The statewide aver age CMR occupancy rate was 69.61
6479percent. These circumstances are not normal.
64859 4 . The portion of CMR discharges covered under traditional
6496Medicare or m anaged Medicare in District 3 is also significantly
6507higher than the state average. This is reasonable since 27.2
6517percent of District 3 Ó s population is 65 and older, while just
653020.1 percent of the statewide population is 65 or older.
65409 5 . In 2016, 74.1 percent of the statewide CMR discharges
6552were covered under traditional or managed Medicare. For
6560District 3 , the number was nearly 81 percent.
65689 6 . Lake County has no CMR services, even though it is the
6582second largest population center in the d istrict.
65909 7 . Waterman is located a significant distance from the CMR
6602providers in District 3. The closure and trans fer of beds from
6614Leesburg Regional Medical CenterÓs CMR unit to The Villages in
6624Sumter County increased the travel time to CMR services for
6634residents of the area. The Villages is still the closest CMR
6645provider to Waterman, but travel from Waterman to The Villages can
6656take 38 minutes to over an hour depending upon traffic and time of
6669year. All other CMR providers are over an hour away, limiting
6680access to CMR services.
66849 8 . ÐConversion rateÑ is the percentage of acute care
6695patients that are discharged to a CMR provider. Analysis of the
6706conversion rate of acute care patients discharged to CMR for both
6717Lake County and Waterman also indicates that the population Ós
6727access to CMR services is limited. The district and state
6737conversio n rate to CMR is approximatel y two percent. The 2016
6749rate for Hernando County was 4.1 percent. The rate for Marion
6760County of 2.6 percent was just over the district average. Lake
6771CountyÓs rate is 1.5 percent, and WatermanÓs is .4 percent. This
6782analysis demonstrates limited access t o CMR services for Lake
6792County residents and residents of WatermanÓs service area. The
6801record offers no other explanation.
68069 9 . The analysis of discharges to CMR beds confirms the
6818analysis. So does physician experience.
6823100 . Like Marion County, Lake Cou nty has a rapidly aging and
6836growing population . As a result, there are many Waterman service
6847area and Lake County residents who are appropriate for and could
6858benefit from CMR, but are not accessing these services due to
6869travel and distance constraints.
687310 1 . The demographic and utilization data presented in this
6884case demonstrate that there is a lack of accessible CMR services
6895for residents in District 3 generally, and in Marion County and
6906Lake County specifically. During the most recent reporting period
6915( 12 months ending on December 31, 2016), the average annual
6926District 3 occupancy rate for the 202 CMR beds was 84.15 percent.
6938Existing CMR services are clustered in just a few areas of this
695016 - county district.
695410 2 . Patients of both applicants suffer from limitations on
6965access to CMR services.
6969CONCLUSIONS OF LAW
697210 3 . The Division of Administrative Hearings has
6981jurisdiction over the parties and the subject matter of these
6991consolidated cases. §§ 120.569, 120.57(1), and 408.039, Fla.
6999Stat.
700010 4 . Each applica nt has standing to participate in this
7012proceeding. § 408.039(5)(c), Fla. Stat.
701710 5 . Sections 408.035, 408.037 , and 408.039 and Florida
7027Administrative Code Rules 59C - 1.008, 59C - 1.030, and 59C - 1.039
7040establish the governing review criteria and procedures. The award
7049of a CON must be based on a balanced consideration of the
7061applicable statutory and rule criteria. Balsam v. DepÓt of H ealth
7072and Rehab. Servs. , 486 So. 2d 1341 (Fla. 1st DCA 1986). The
7084appropriate weight to give each criterion is not fixed. It varies
7095based upon the facts of the case. See, e .g. , Morton F. Plant
7108Hosp. AssÓn, Inc. v. DepÓt of H ealth and Rehab. Servs. , 491 So. 2d
7122586, 589 (Fla. 1st DCA 1986) (quoting North Ridge Gen. Hosp., Inc.
7134v. NME Hosp., Inc. , 478 So. 2d 1138, 1139 (Fla. 1st D CA 1985));
7148Collier Med. Ctr., Inc. v. DepÓt of H ealth and Rehab. Servs. , 462
7161So. 2d 83, 84 (Fla. 1st DCA 1986).
716910 6 . A CON applicant must prove by a preponderance of the
7182evidence that its CON application should be approved. See , e.g. ,
7192Boca Raton Artifici al Kidney Ctr., Inc. v. DepÓt of H ealth and
7205Rehab. Servs. , 475 So. 2d 260, 263 (Fla. 1st DCA 1985);
7216§ 120.57(1)(j), Fla. Stat.
722010 7 . An administrative hearing involving disputed issues of
7230material fact is a de novo proceeding in which the Administrative
7241L aw Judge independently evaluates the evidence presented. Fla.
7250DepÓt of Transp. v. J.W.C. Co., Inc. , 396 So. 2d 778, 787 (Fla.
72631st DCA 1981); £ 120.57(1), Fla. Stat. The AgencyÓs preliminary
7273decision and its findings in the St ate Agency Action Report (SAA R)
7286are not entitled to a presumption of correctness.
7294Application Content
729610 8 . West Marion and Watermark satisfy the application
7306content requirements of section 408.037 a nd r ule 59C - 1.039.
7318Section 408.035(l)(b) - The availability, quality of
7325care, accessib ility, and extent of utilization of
7333existing health care facilities and health services in
7341the service district of the applicant.
734710 9 . Both applicants proved that there is a lack of
7359accessibility to CMR beds for patients from their respective
7368service are a due to Ðnot normal circumstances,Ñ including the
7379extremely high utilization rate of CMR beds in District 3 which
7390results in patients needing CMR services receiving some
7398rehabilitation services in skilled nursing units or at home with
7408the assistance of ho me health providers. Both, in fact, presented
7419persuasive evidence that discharges from each hospital alone would
7428generate most of the projected utilization for each applicantÓs
7437proposed unit.
7439Section 408.035(1)(e) - The extent to which the proposed
7448servi ces will enhance access to health care for
7457residents of the service district.
74621 10 . Rule 59C - 1.039(6) says that CMR services should be
7475available within a maximum ground travel time of two hours under
7486average travel conditions for at least 90 percent of th e
7497districtÓs population. Existing facilities satisfy this minimum
7504standard. The evidence proved, however, that existing CMR
7512facilities are not as a practical matter providing full
7521accessibility due to abnormally high utilization , selective
7528admission crit eria, patient resistan ce to travel , and travel
7538limitations on friends and family. West Marion and Waterman will
7548both enhance access to residents in their respective service
7557areas. There will be no adverse effect to either facility if both
7569CON a pplication s are approved. There is also no persuasive
7580evidence that approval of both applications would have an adverse
7590impact on existing providers in the district.
7597Section 408.035(l)(i) - The applicant's past and
7604proposed provisions of health care services to Med icaid
7613patients and the medically indigent.
76181 11 . Both applicants demonstrated that they provide services
7628to Medicaid patients and the medically indigent. West Marion,
7637however, offers to condition its CON on a requirement that Ð a
7649minimum of 7% of the pati ents in the CMR Unit would be some
7663combination of Medicaid, as well as self - pay. Ñ It also projects
7676serving more Medicaid and self - pay/charity patients than Waterman.
7686Thus, West Marion demonstrates a stronger commitment to serving
7695the Medicaid/ c harity c ar e population. Approval of its application
7707will substantially improve access to CMR services for Medicaid,
7716indigent, and self - pay patients.
7722Summary Comparison
772411 2 . The Findings of Fact establish that West Marion and
7736Waterman satisfy the criteria of the g overning statutes and rules.
7747Either could be approved for the 12 CMR beds for which the Agency
7760published a need. Waterman and West Marion both present sound
7770proposals .
777211 3 . The persuasive and essentially unrebutted evidence also
7782proves Ðnot normal circu mstancesÑ supporting approval of at least
779212 CMR beds in addition to the 12 for which the Agency calculated
7805a need. The applicants serve different market s. Approval of two
7816programs will not adversely affect either applicant. However, a
7825comparative revie w of the two proposals requires a conclusion
7835that , for two reasons , Waterman is the better choice to fill the
7847calculated need.
784911 4 . First, the access limitations faced by the patients
7860that Waterman serves are more severe than those faced by West
7871MarionÓ s patients. Consequently, Waterman will enhance health
7879care access to a gre ater extent than West Marion.
7889§ 408.035(1)(e) , Fla. Stat .
789411 5 . Second, the resources available to Waterman due to its
7906outpatient rehabilitation unit, the Florida Hospital Waterm an
7914Rehabilitation Institute, buttressed by the resources offered by
7922the Florida Hospital System are superior to those availabl e to
7933West Marion. § 408.035(1)(d), Fla. Stat. This is in no way,
7944however, a conclusion that West Marion does not have adequate
7954r esources to successfully open and operate its proposed CMR unit.
7965Approval of Two CONs
796911 6 . The Agency opposes approving either application on Ðnot
7980normal circumstancesÑ grounds. It is worth noting again that the
7990Agency did not present a factual case to support its argument,
8001only legal theories. The Agency offers three arguments to support
8011its position. The first is that the applicants did not seek
8022approval based upon Ðnot normal circumstances.Ñ The second is
8031that the applications did not comply with the requirements of r ule
804359C - 1.008(2)(d). The third is that seeking approval on a Ð not
8056normal circumstancesÑ theory in this proceeding amounts to an
8065impermissible amendment to the application. This argument
8072subsumes the first argument.
807611 7 . The record a nd the findings based upon it show that
8090both applicants incorporated a Ðnot normal circumstancesÑ theory
8098into their applications. For this reason, the impermissible
8106amendment argument fails. The Agency cites Community Hospice of
8115Northeast Florida, Inc. v . Agency for Health Care Administration ,
8125Case No. 10 - 1865CON (Fla. DOAH March 22, 2011; Fla. AHCA May 1,
81392011) to support its argument. The facts of that case differ from
8151the facts of this case. In Community Hospice , one of the
8162applicants, United Hospice of Florida, Inc., raised a new theory
8172for approval of its application. It argued that a second hospice
8183program should be approved, in addition to the one for which the
8195Agency had calculated a need, because of low utilization by
8205minorities and because the need projections showed a very large
8215number of new admissions to hospice programs.
822211 8 . The O rder explained why this was a new theory, a new
8237proposal, and, therefore, an impermissible amendment.
8243This change is so material that it amounts to
8252an impermissi ble amendment under Manor Care,
8259Inc. v. Department of Health and
8265Rehabilitative Services . The theory requires
8271a different analysis of all the information
8278provided in the applications, an analysis that
8285neither the applicants nor the Agency
8291conducted during the initial review. The
8297applications only provided information about
8302how to best fill the projected need for one
8311program. The applications contain no
8316information or analysis about what the effect
8323of approving two new programs would be on
8331existing provid ers. The applications contain
8337no information about what utilization each
8343program could expect if two programs are
8350approved or what the effect of that
8357utilization would be on the existing provider
8364and the other applicant. In short the new
8372theory materiall y changes the United proposal.
837911 9 . This case is different. There are no material
8390differences between the information and arguments that West Marion
8399and Waterman made in their applications and those presented in the
8410hearing. The applications provided i nformation specific to each
8419facility and to its patient population and service area to support
8430approval. The applications specifically said that approval of
8438programs at either or both facilities would not affect utilization
8448of the other proposed program o r existing providers. Comments in
8459the SAAR reveal that the Agency gleaned that the applicants relied
8470upon their institution - specific and market - specific need as well
8482as the calculated need.
8486120. Page 20 of the SAAR notes that WatermanÓs application
8496Ðdi scusses institution - specific need for CMR beds.Ñ Page 51 of
8508the SAAR observes that West Marion Ðanticipates additional bed
8517need to address availability and accessibility problems due to
8526overutilization.Ñ On the same page, the SAAR recognizes the
8535institut ion - specific and market - specific nature of West MarionÓs
8547proposal: ÐWMCH contends that the general shortage of CMR beds in
8558District 3, specifically Marion County, justifies approval of the
8567proposed program.Ñ
85691 21 . The same distinction applies to North Bro ward Hospital
8581District , d/b/a Broward Health Medical Center v. Agency for Health
8591Care Administration , Case No. 15 - 5549CON (Fla. DOAH May 4, 2016;
8603Fla. AHCA June 2, 2016), also relied upon by the Agency. The
8615applicant there proposed one kidney transplant p rogram in its
8625application and two at the hearing.
8631122 . West Marion and Waterman have done nothing similar in
8642this proceeding . Both seek to fill the calculated need. Both
8653also argue that institution - specific and county - specific factors
8664support granting them CMR beds. The same facts support both
8674theories. Neither applicant has amended its proposal.
8681123 . The Agency maintains that r ule 59C - 1.008(2)(d)
8692prohibits seeking approval of beds on Ðnot normal circumstancesÑ
8701grounds for a project seeking the same number of beds as the
8713number projected by the Agency. The rule does not say that. It
8725states:
8726(d) The Agency will follow these procedures
8733when awarding beds or services identified in a
8741Fixed Need Pool:
87441. Beds or services will be awarded based on
8753the a vailability of a qualified applicant and
8761proposed project which meets statutory review
8767criteria.
87682. In the absence of a qualified applicant
8776and a project which meets statutory review
8783criteria, the Agency may elect not to approve
8791any applications for beds or services.
87973. If a qualified applicant exists but the
8805proposed project exceeds the beds or services
8812identified in the Fixed Need Pool, the Agency
8820may award beds or services in excess of the
8829pool when warranted by special circumstances
8835as defined in th e applicable section of
8843Chapter 59C - 1, F.A.C., for the particular type
8852of bed or service.
885612 4 . The AgencyÓs theory is that it does not have authority
8869to approve the two applications here on the basis of Ðnot normal
8881circumstances,Ñ because neither applica tion is in excess of the
8892fixed need pool. The theory fails first because of the lack of a
8905factual premise. As discussed above , both applicants sought
8913approval on grounds other than the fixed need pool . This
8924necessarily means their proposed projects exce eded the fixed need
8934pool.
893512 5 . The theory fails second because under the theory if
8947either applicant sought 13 beds the Agency could approve the
8957application, but it cannot since each applicant sought 12. The
8967theory violates the common sense interpretati on principle.
8975Cf. Sch. Bd. v. Survivors Charter Schs., Inc. , 3 So. 3d 1220, 1235
8988(Fla. 2009) (Ð We are not required to abandon either our common
9000sense or principles of logic in statutory interpretation.Ñ) .
900912 6 . Third, the theory is contrary to previous Agency
9020decisions where the Agency has awarded multiple CONS based on not
9031normal circumstances, even though there was no publication of
9040need. See HealthSouth Reha b. Hosp . of Seminole Cty. LLC v. A gency
9054for Health Care Admin. , Case No. 12 - 0425CON ( Fla. AHC A May 11,
90692012)(adopting settlement agreement permitting a 50 - bed CMR
9078hospital based on not normal circumstances) 5/ ; Osceola Reg Ó l Hosp .
9091Inc. , d/b/a Osceola Reg Ól Med . Ctr . v. A g . for Health Care Admin. ,
9108Case No. 15 - 38 31 CON ( Fla. DOAH Mar . 22, 2016, Fla. A HCA
9125Apr. 14, 2016) (approving through settlement agreement two CONs for
9135CMR beds based on a showing of not normal circumstances) 6/ ; see
9147also Fla. Admin. Code R. 59C - 1.008(2)(d)3.
915512 7 . The Agency does not identify a f inal o rder or court
9170opinion establish ing the interpretation that it advocates. The
9179Agency does cite a number of cases expressing the principle of
9190deference to Agency interpretations. The adoption of Article XI,
9199section 5(e) to the Florida Constitution casts doubt on the
9209persuasiveness of th at argument. In any event, the AgencyÓs
9219interpretation of the rule is not reasonable or consistent with
9229other parts of the same rule.
9235RECOMMENDATION
9236Based on the foregoing Findings of Fact and Conclusions of
9246Law, it is RECOMMENDED that :
9252A. The Agency for Health Care Administration render a f inal
9263o rder granting Florida Hospital Waterman, Inc., d/b/a Florida
9272Hospital Waterman, a Certificate of Need to establish 12
9281Comprehensive Medical Rehabilitation Beds.
9285B. The Agency for Health Care Administration rende r a f inal
9297o rder granting Marion Community Hospital, Inc., d/b/a West Marion
9307Community Hospital and Ocala Regional Medical Center, a
9315Certificate of Need to establish 12 Comprehensive Medical
9323Rehabilitation Beds.
9325DONE AND ENTERED this 6 th day of February , 20 19 , in
9337Tallahassee, Leon County, Florida.
9341S
9342JOHN D. C. NEWTON, II
9347Administrative Law Judge
9350Division of Administrative Hearings
9354The DeSoto Building
93571230 Apalachee Parkway
9360Tallahassee, Florida 32399 - 3060
9365(850) 488 - 9675
9369Fax Filing (850) 921 - 6847
9375www.doah.state.fl.us
9376Filed with the Clerk of the
9382Division of Administrative Hearings
9386this 6 th day of February , 2019 .
9394ENDNOTES
93951/ All citations to Florida Statutes are to the 2018 codification
9406unless otherwise noted.
94092/ Munroe HMA Hospital applied for the 12 CMR beds also and
9421challenged its denial. But it has been dismissed from this
9431proceeding.
94323/ This is a reference to a geographic are a not a specific
9445location or facility although the record leaves the impression
9454that the r eference is to Jacksonville, Florida.
94624/ ÐWMÑ refers to West Marion Exhibits. ÐWHÑ refers to Waterman
9473Hospital exhibits.
94755/ See Case No. 12 - 0425CON, Petition for Formal Administrative
9486Hearing , filed January 12, 2012.
94916/ See Case No. 15 - 3831CON, Peti tion for Formal Administrative
9503Hearing , filed July 2, 2015.
9508COPIES FURNISHED:
9510Mia L. McKown, Esquire
9514Holland & Knight LLP
9518Suite 600
9520315 South Calhoun Street
9524Tallahassee, Florida 32301
9527(eServed)
9528Kevin Michael Marker, Esquire
9532Agency for Health Care Admi nistration
9538Mail Stop 7
95412727 Mahan Drive
9544Tallahassee, Florida 32308
9547(eServed)
9548Lindsey L. Miller - Hailey, Esquire
9554Agency for Health Care Administration
9559Mail Stop 7
95622727 Mahan Drive
9565Tallahassee, Florida 32308
9568(eServed)
9569Richard Joseph Saliba, Esquire
9573Agency for Health Care Administration
9578Fort Knox Building III, Mail Stop 7
95852727 Mahan Drive
9588Tallahassee, Florida 32308
9591(eServed)
9592Stephen A. Ecenia, Esquire
9596Rutledge Ecenia, P.A.
9599Suite 202
9601119 South Monroe Street
9605Tallahassee, Florida 32301
9608(eServed)
9609David Mark Maloney, Esquire
9613Rutledge Ecenia P.A.
9616Suite 202
9618119 South Monroe Street
9622Tallahassee, Florida 32301
9625(eServed)
9626Craig D. Miller, Esquire
9630Rutledge Ecenia, P.A.
9633Suite 202
9635119 South Monroe Street
9639Tallahassee, Florida 32301
9642(eServed)
9643J. Stephen Menton, Esqui re
9648Rutledge Ecenia, P.A.
9651Suite 202
9653119 South Monroe Street
9657Tallahassee, Florida 32301
9660(eServed)
9661Stephen K. Boone, Esquire
9665Boone, Boone, Boone, and Koda, P.A.
96711001 Avenida Del Circo
9675Post Office Box 1596
9679Venice, Florida 34284
9682(eServed)
9683Tiffany A. Roddenb erry, Esquire
9688Holland & Knight, LLP
9692Suite 600
9694315 South Calhoun Street
9698Tallahassee, Florida 32301
9701(eServed)
9702Richard J. Shoop , Agency Clerk
9707Agency for Health Care Administration
97122727 Mahan Drive, Mail Stop 3
9718Tallahassee, Florida 32308
9721(eServed)
9722Mary C. Mayhew , Secretary
9726Agency for Health Care Administration
97312727 Mahan Drive, Mail Stop 1
9737Tallahassee, Florida 32308
9740(eServed)
9741Stefan Grow , General Counsel
9745Agency for Health Care Administration
97502727 Mahan Drive, Mail Stop 3
9756Tallahassee, Florida 32308
9759(eSer ved)
9761NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
9767All parties have the right to submit written exceptions within
977715 days from the date of this Recommended Order. Any exceptions
9788to this Recommended Order should be filed with the agency that
9799will issue the Final Order in this case.
- Date
- Proceedings
- PDF:
- Date: 03/12/2019
- Proceedings: Marion Community Hospital, Inc. d/b/a West Marion Community Hospital and Ocala Regional Medical Center's Exceptions to the Recommended Order (filed in Case No. 18-000075CON).
- PDF:
- Date: 03/12/2019
- Proceedings: Agency for Health Care Administration's Exceptions to the Recommended Order (filed in Case No. 18-000075CON).
- PDF:
- Date: 02/06/2019
- Proceedings: Recommended Order (hearing held June 18-22 and 25, 2018). CASE CLOSED.
- PDF:
- Date: 02/06/2019
- Proceedings: Recommended Order cover letter identifying the hearing record referred to the Agency.
- PDF:
- Date: 11/14/2018
- Proceedings: Notice of Telephonic Status Conference (status conference set for November 27, 2018; 3:00 p.m.).
- PDF:
- Date: 08/28/2018
- Proceedings: Florida Hospital Waterman, Inc.'s Memorandum of Law in Support of the Proposed Recommended Order filed.
- PDF:
- Date: 08/28/2018
- Proceedings: Agency Memorandum of Law Submitted Pursuant to Section 28-106.307 Uniform Rules of Procedure Agency Notice of Adoption of Waterman's Proposed Recommended Order filed.
- PDF:
- Date: 08/27/2018
- Proceedings: Marion Community Hospital, Inc. d/b/a West Marion Community Hospital and Ocala Regional Medical Center's Notice of Filing the Deposition Transcript of James Duke, M.D. filed.
- PDF:
- Date: 08/15/2018
- Proceedings: Unopposed Motion to Extend the Deadline for Post-Hearing Submissions filed.
- PDF:
- Date: 07/18/2018
- Proceedings: Marion Community Hospital, Inc. d/b/a West Marion Community Hospital's Report of Plan for Testimony of Cory Hewitt filed.
- PDF:
- Date: 07/02/2018
- Proceedings: Response to Order Advising ALJ of Testimony and Motion for Additional Time filed.
- PDF:
- Date: 06/29/2018
- Proceedings: Unopposed Motion to Extend the Deadline for Post-hearing Submissions filed.
- PDF:
- Date: 06/13/2018
- Proceedings: Motion for Extension of Time to File Joint Pre-hearing Stipulation filed.
- PDF:
- Date: 06/12/2018
- Proceedings: Notice of Taking Depositions and Amended Notice of Taking Deposition for Marisol Fitch filed.
- PDF:
- Date: 06/04/2018
- Proceedings: Notice of Telephonic Conference (conference set for June 4, 2018; 11:00 a.m.).
- PDF:
- Date: 06/04/2018
- Proceedings: Order on Objection to Depositions and Extending Pre-hearing Stipulation Filing Date.
- Date: 06/04/2018
- Proceedings: CASE STATUS: Motion Hearing Held.
- PDF:
- Date: 06/04/2018
- Proceedings: Agency for Health Care Administration's Objection to Untimely Notice of Depositions filed.
- PDF:
- Date: 05/16/2018
- Proceedings: Amended Notice of Hearing (hearing set for June 18 through 22 and 25 through 27, 2018; 9:00 a.m.; Tallahassee, FL; amended as to Hearing Dates).
- PDF:
- Date: 05/10/2018
- Proceedings: Response to Order Severing Case No. 18-0071, Closing File, Relinquishing Jurisdiction filed.
- PDF:
- Date: 05/03/2018
- Proceedings: Order Severing Case No. 18-0071, Closing File, and Relinquishing Jurisdiction (filed in DOAH Case No. 18-0071).
- PDF:
- Date: 04/30/2018
- Proceedings: Munroe Regional's Notice of Service of Answers and Objections to Florida Hospital Waterman's First Set of Interrogatories filed.
- PDF:
- Date: 04/30/2018
- Proceedings: Munroe Regional's Responses to Florida Hospital Waterman's First Request for Production filed.
- PDF:
- Date: 04/25/2018
- Proceedings: Order Denying Request for Leave to Reply of Marion Community Hospital, Inc., and Florida Hospital Waterman, Inc.
- PDF:
- Date: 04/24/2018
- Proceedings: Florida Hospital Waterman, Inc.'s Responses to Second Request for Production of Documents by Munroe HMA Hospital, LLC filed.
- PDF:
- Date: 04/24/2018
- Proceedings: Florida Hospital Waterman, Inc.'s Responses to First Request for Production of Documents by Munroe HMA Hospital, LLC filed.
- PDF:
- Date: 04/24/2018
- Proceedings: Florida Hospital Waterman, Inc.'s Answers and Objections to Munroe Regional Medical Center's First Set of Interrogatories filed.
- PDF:
- Date: 04/18/2018
- Proceedings: Munroe Regional's Response in Opposition to West Marion, Ocala Regional, and Florida Hospital Waterman Inc.'s Request for Leave to Reply filed.
- PDF:
- Date: 04/17/2018
- Proceedings: Notice of Telephonic Status Conference (status conference set for April 20, 2018; 2:30 p.m.).
- PDF:
- Date: 04/16/2018
- Proceedings: West Marion Community Hospital and Ocala Regional Medical Center Final Witness List filed.
- PDF:
- Date: 04/16/2018
- Proceedings: Notice of Telephonic Status Conference (status conference set for April 20, 2018; 2:30 p.m.).
- PDF:
- Date: 04/12/2018
- Proceedings: West Marion, Ocala Regional, and Florida Hospital Waterman's Request for Leave to Reply filed.
- PDF:
- Date: 04/06/2018
- Proceedings: Munroe Regional's Response in Opposition to Florida Hospital Waterman Inc's Motion to Dismiss filed.
- PDF:
- Date: 03/05/2018
- Proceedings: Florida Hospital Waterman, Inc.'s Preliminary Witness List filed.
- PDF:
- Date: 03/02/2018
- Proceedings: West Marion Community Hospital's First Request for Production of Documents to Florida Hospital Waterman filed.
- PDF:
- Date: 03/02/2018
- Proceedings: West Marion Community Hospital's First Request for Production of Documents to Munroe Regional Medical Center filed.
- PDF:
- Date: 02/26/2018
- Proceedings: West Marion Community Hospital and Ocala Regional Medical Center Preliminary Witness List filed.
- PDF:
- Date: 02/21/2018
- Proceedings: Florida Hospital Waterman's Notice of Service of It's First Set of Interrogatories to Munroe HMA Hospital, LLC filed.
- PDF:
- Date: 02/21/2018
- Proceedings: Florida Hospital Waterman's Notice of Service of It's First Set of Interrogatories to Marion Community Hospital d/b/a West Marion Community Hospital filed.
- PDF:
- Date: 02/21/2018
- Proceedings: Florida Hospital Waterman, Inc., d/b/a Florida Hospital Waterman's First Request for Production to Munroe HMA Hospital, LLC filed.
- PDF:
- Date: 02/21/2018
- Proceedings: Florida Hospital Waterman, Inc., d/b/a Florida Hospital Waterman's First Request for Production to Marion Community Hospital , Inc. d/b/a West Marion Community Hospital filed.
- PDF:
- Date: 02/16/2018
- Proceedings: Munroe Regional Medical Center's Notice of Serving First Interrogatories to West Marion Community Hospital filed.
- PDF:
- Date: 02/16/2018
- Proceedings: Munroe Regional Medical Center's Notice of Serving First Interrogatories to Florida Hospital Waterman filed.
- PDF:
- Date: 02/16/2018
- Proceedings: Munroe Regional Medical Center's Second Request for Production of Documents to West Marion Community Hospital filed.
- PDF:
- Date: 02/16/2018
- Proceedings: Munroe Regional Medical Center's First Request for Production of Documents to West Marion Community Hospital filed.
- PDF:
- Date: 02/16/2018
- Proceedings: Munroe Regional Medical Center's Second Request for Production of Documents to Florida Hospital Waterman filed.
- PDF:
- Date: 02/16/2018
- Proceedings: Munroe Regional Medical Center's First Request for Production of Documents to Florida Hospital Waterman filed.
- PDF:
- Date: 01/29/2018
- Proceedings: Joint Notice of Filing Proposed Order of Pre-hearing Instructions filed.
- PDF:
- Date: 01/25/2018
- Proceedings: The Agency for Health Care Administration's Preliminary and Final Witness List filed.
- PDF:
- Date: 01/18/2018
- Proceedings: Notice of Appearance (Tiffany Roddenberry; filed in Case No. 18-000075CON).
- PDF:
- Date: 01/18/2018
- Proceedings: Notice of Appearance (Mia Mckown; filed in Case No. 18-000075CON).
- PDF:
- Date: 01/18/2018
- Proceedings: Notice of Hearing (hearing set for June 18 through 22 and 25 through 29, 2018; 8:30 a.m.; Tallahassee, FL).
- PDF:
- Date: 01/11/2018
- Proceedings: Order of Consolidation (DOAH Case Nos. 18-0068CON, 18-0071CON, and 18-0075CON)).
Case Information
- Judge:
- JOHN D. C. NEWTON, II
- Date Filed:
- 01/05/2018
- Date Assignment:
- 01/08/2018
- Last Docket Entry:
- 03/12/2019
- Location:
- Tallahassee, Florida
- District:
- Northern
- Agency:
- Other
- Suffix:
- CON
Counsels
-
Stephen K. Boone, Esquire
1001 Avenida Del Circo
Post Office Box 1596
Venice, FL 34284
(941) 488-6716 -
Stephen A Ecenia, Esquire
119 South Monroe Street, Suite 202
Post Office Box 551
Tallahassee, FL 32301
(850) 681-6788 -
Kevin Michael Marker, Esquire
Mail Stop 7
2727 Mahan Drive
Tallahassee, FL 32308
(850) 412-3496 -
Mia L. McKown, Esquire
Suite 600
315 South Calhoun Street
Tallahassee, FL 32301
(850) 425-5663 -
Lindsey L. Miller-Hailey, Esquire
Mail Stop 7
2727 Mahan Drive
Tallahassee, FL 32308
(850) 412-3941 -
Tiffany A. Roddenberry, Esquire
Suite 600
315 South Calhoun Street
Tallahassee, FL 32301
(850) 224-7000 -
Richard Joseph Saliba, Esquire
Fort Knox Building III, Mail Stop 7
2727 Mahan Drive
Tallahassee, FL 32308
(850) 412-3666 -
Geoffrey D. Smith, Esquire
Suite 202
1499 South Harbor City Boulevard
Melbourne, FL 32901
(321) 676-5555 -
Stephen A. Ecenia, Esquire
119 South Monroe Street, Suite 202
Post Office Box 551
Tallahassee, FL 32301
(850) 681-6788