92-005107CON University Community Hospital vs. Agency For Health Care Administration Status: Closed Recommended Order on Tuesday, October 19, 1993.

Summary: Comprehensive medical rehabilitation bed need established despite zero numeric need due to geographic inaccessibility and district use rate.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

UNIVERSITY COMMUNITY HOSPITAL, )

)

Petitioner, )

)

vs. ) CASE NO. 92-5107

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

________________________________)

RECOMMENDED ORDER

This case was heard by Eleanor M. Hunter, the Hearing Officer designated by

the Division of Administrative Hearings, on January 25 -26, 1993, in

Tallahassee, Florida.

APPEARANCES

For Petitioner, Cynthia S. Tunnicliff, Attorney

Community W. Douglas Hall, Attorney

Hospital: Carlton, Fields, Ward, Emmanuel,

Smith & Cutler, P.A.

Post Office Drawer 190

Tallahassee, Florida 32302

For Respondent, Lesley Mendelson, Senior Attorney

Agency for Agency for Health Care Administration

Health Care 2727 Mahan Drive

Administration: Tallahassee, Florida 32308

STATEMENT OF THE ISSUE

Whether University Community Hospital should be issued Certificate of Need

Number 6936 to convert 20 acute care beds to 20 comprehensive medical

rehabilitation beds.

PRELIMINARY STATEMENT

On February 7, 1992, the Department of Health and Rehabilitative Services,

the agency responsible for the administration of the Certificate of Need ("CON")

program prior to the Agency for Health Care Administration ("AHCA"), published a

fixed need pool of zero for additional comprehensive medical rehabilitation beds

in District 6. District 6 includes Hillsborough, Manatee, Polk, Hardee and

Highlands Counties.

In March 1992, University Community Hospital ("UCH") filed a letter of

intent to file an application for a CON to convert 20 medical/surgical acute

care beds to 20 comprehensive medical rehabilitation beds. The application was

filed and reviewed, and the agency published its intent to deny the application

which had subsequently been numbered CON 6936. Vol. 18, No. 29, Florida

Administrative Weekly, July 17, 1992. A timely filed petition, challenging the

intent to deny CON 6936, was forwarded to the Division of Administrative

Hearings and initiated these proceedings.

At the final hearing, UCH presented the testimony of Brigitte Shaw, the

hospital's planner; Sandra Williams, its Vice President for Fiscal Services and

an expert in health care finance; and Scott L. Hopes, expert in health care

planning. UCH's Exhibits 1-8 were received into evidence, with ruling reserved

on a proffered Exhibit 9. On February 3, 1993, AHCA filed a Notice of

Withdrawal of Objection to Exhibit 9, which was received in evidence. AHCA

presented the testimony of Jon Cooper, expert in architecture, and Alberta

Granger, expert in health planning related to CON review, and Exhibits 1-7 which

were received in evidence.

Subsequent to the hearing on February 3, 1993, AHCA filed a Request For

Official Recognition of Winter Haven Hospital v. Department of Health and

Rehabilitative Services, DOAH Case No. 85-4133 (HRS Final Order 9/8/86). In

that case, the Department of Health and Rehabilitative Services ("HRS") approved

the conversion of 24 medical/surgical beds at Winter Haven Hospital to

comprehensive medical rehabilitation beds, conditioned on the filing by Winter

Haven of a request to delicense an additional 16 medical/surgical beds.

FINDINGS OF FACT

1. UCH is a 424 bed acute care hospital located in northern Hillsborough

County. UCH is the applicant for CON Number 6936 to convert 20 medical/surgical

acute care beds to 20 comprehensive medical rehabilitation ("CMR") beds. Its

service area is northern Hillsborough and eastern Pasco Counties.

2. AHCA is the successor to HRS as the designated agency to administer the

CON laws.

3. UCH currently operates 404 acute care beds and 20 skilled nursing beds.

Its services include an emergency room, open heart surgery, obstetrics, and a

home health agency.

4. From 1982 to 1990, UCH operated an inpatient comprehensive

rehabilitation unit, certified by HRS and recognized by the Federal Health Care

Finance Administration ("HCFA") as a 9-bed unit in 1984, and as an 18-bed unit

from 1985 through 1988. Substantial renovation of the unit's sixth floor south

wing, in 1987 and 1988, was intended to meet the standards of the Commission on

Accreditation of Rehabilitation Facilities ("CARF"). UCH was never actually

CARF accredited.

5. After the enactment of a CMR rule, HRS preliminarily determined that

UCH was a "grandfathered" 9-bed provider of CMR services. That preliminary

determination was successfully challenged in University Community Hospital v.

Department of Health and Rehabilitative Services, 11 FALR 1150 (HRS Final Order

2/13/89), and the unit was closed in 1990. In September 1990, UCH applied for

CON 6412 to convert 20 acute care beds to 20 CMR beds. That application was

denied. University Community Hospital v. Department of Health and

Rehabilitative Services, et al., 14 FALR 1899 (HRS Final Order 4/15/92).

NEED IN RELATION TO STATE AND LOCAL HEALTH PLAN

6. Five preferences in the 1989 Florida State Health Plan relate to CMR

programs and are applicable to the review of the UCH application.

7. The first preference relates to applicants proposing the conversion of

excess acute care beds to establish a distinct rehabilitation unit within a

hospital. AHCA agrees that the UCH application is consistent with this

preference.

8. The second preference, favoring applicants proposing specialty

inpatient or outpatient rehabilitation services not currently offered in the

district, it not met. In District VI, three CMR providers have a total of 112

licensed beds, 111 beds in operation: 59 at Tampa General Hospital in

Hillsborough County, 24 at Winter Haven Hospital in Polk County, and 28 at L.W.

Blake in Manatee County.

9. The third preference applies to the teaching hospitals. UCH is not a

teaching hospital although it does have contracts with teaching institutions to

allow students to gain clinical experience at UCH. See, Subsection

408.035(1)(g), Fla. Stat. (1992 Supp.).

10. The fourth preference, is for applicants with a history of providing a

disproportionate share of charity care and Medicaid patient days. The

preference specifically requires qualifying hospitals to meet Medicaid

disproportionate share hospital criteria. UCH is not a disproportionate share

provider, and does not meet this preference.

11. The fifth preference, for applicants with an existing comprehensive

outpatient rehabilitation facility ("CORF"), is met. UCH planner's testimony

was not refuted and AHCA concedes that UCH offers a number of therapies to

outpatients.

12. The June 1990 District VI Allocation Factors Report, prepared by the

Health Council of West Central Florida, Inc., is the local health plan

applicable to the review of this application.

13. The first preference favors disproportionate share providers, and does

not support the UCH application. See, Finding of Fact 10.

14. UCH is entitled to the second local preference for the conversion of

existing medical/surgical beds. See, Finding of Fact 7.

15. The fourth preference is for existing providers of fewer than 20 beds

seeking to add more beds and is, therefore, not applicable to the UCH

application.

POPULATION CONDITIONS AND NEED

16. The third local preference, for additional rehabilitation services if

existing ones are not meeting community needs, is the essence of the UCH claim

that its services are needed. The local factor is also directly related to the

criteria of Subsection 408.035(1)(b), Florida Statutes, and Florida

Administrative Code, Rule 59C-1.039(2)(b). The rule is as follows:

1. Historic, current and projected

incidence and prevalence of disabling

conditions and chronic illness in the

population in the Department service district

by age and sex group;

ends in utilization by third party

payers;

3. Existing and projected inpatients

(e.g., orthopedic, stroke and cardiac cases)

in need of rehabilitation services; and

4. The availability of specialized

staff.

17. Based on rule methodology for computing numeric need, there is zero

need for additional CMR beds in District VI. That methodology is based on the

assumption that there will be 3.9 CMR beds needed for every 1000 acute care

discharges.

18. In terms of population conditions, UCH has urged the consideration of

the actual statewide use rate of 8.46 CMR admissions for every 1000 acute care

admissions, which would equate to a need for an additional 132 beds in the

District. In District VI, there are 6.67 CMR admissions for every 1000 acute

care admissions which, considering projected population increases, equates to a

need for 80 additional beds. According to UCH, CMR bed availability is a factor

in determining utilization

19. In District VI, there are 7 CMR beds per 100,000 people. UCH points

to the actions of AHCA in approving an increase from 8 to 12 CMR beds per

100,000 people in District IX in the absence of any published numeric need.

20. AHCA emphasizes that empty CMR beds exist in District VI, which had

1990-1991 occupancy rates of 72.07 percent, below the 85 percent minimum for

approval of new beds absent not normal circumstances. Tampa General's rate was

82.77 percent, but Winter Haven's was 50.82 percent and L. W. Blake in Manatee

County was 67.36 percent occupied. As AHCA also indicated, population

projections and numeric need are calculated to determine future need.

21. UCH has demonstrated that the geographic and economic accessibility of

Winter Haven in Polk County is limited for patients from the UCH area. In part,

the limitations result from the requirement of third party payers for CARF

accredited facilities, when intense, inpatient rather than outpatient CMR

services are needed. Winter Haven is not CARF accredited. In addition, during

the time there was a low rate of utilization at Winter Haven, some licensed beds

were not in service due to construction. Utilization in the first quarter of

1992 reached just under 80 percent at Winter Haven. UCH also claims that AHCA

approved beds at Winter Haven based on the geographic inaccessibility of beds in

Tampa. AHCA filed a Request for Official Recognition on February 3, 1993, which

shows the award of beds to Winter Haven resulted from a stipulated settlement.

UCH's Exhibit 9 does include the distance to Tampa as one of several factors

considered in the agency's approval of the stipulated settlement with Winter

Haven.

22. L. W. Blake in Manatee County is also geographically inaccessible for

Hillsborough County patients and their families, particularly the elderly

proposed to be served by UCH. In addition, L.W. Blake's utilization increased

to an average of 84 percent in the first quarter of 1992.

23. Tampa General has 59 of its 60 CMR beds in service. All rooms at

Tampa General are semi-private, necessitating same gender placements, except one

isolation room. In addition, patients with similar injuries are grouped

together. Tampa General is a regional referral center for vocational

rehabilitation and a state designated center for head and spinal cord injuries.

These factors limit the availability of Tampa General's beds to serve District

VI residents, as does its occupancy rate of 85 percent. In the past, when UCH

operated and then closed a CMR unit, there was no statistical impact on Tampa

General. Currently, Tampa General has a waiting list and patients average a 9

day wait.

24. For the reasons identified by UCH, including geographic and economic

inaccessibility, the district incidence of CMR admissions as compared to acute

care admissions, UCH has provided sufficient, credible evidence of the need for

the services proposed by UCH in additional CMR beds in District VI.

25. AHCA has amended its CMR rule to better predict need. Although it is

not applicable to computing numeric need for this cycle, AHCA asserts that its

new rule methodology is the alternative which should be used rather than other

factors, such as the ratio of CMR beds to acute care admissions, or population.

Under the new rule methodology, there is no numeric need for additional CMR beds

in District VI. Assuming arguendo, that AHCA is correct, the other factors

related to the accessibility and availability of services at the three existing

providers could not be disregarded.

PROJECT COSTS AND FINANCIAL FEASIBILITY

26. In this application, UCH proposes to operate a 20-bed CMR unit in the

renovated space of the sixth floor south wing. That space currently is being

used as an overflow area for 30 medical/surgical beds.

27. UCH estimates total project costs of $248,596, with major expenses for

consulting, legal, and accounting expenses, and $67,496 of the total or $3.66

per square foot for redecorating the renovated wing. No additional construction

is anticipated. AHCA acknowledges that UCH has the funds to finance the

project, but asserts that the costs are understated by $150,000 due to the

failure of UCH to include construction costs to bring the wing into compliance

with the Americans with Disabilities ACT ("ADA"). UCH notes, and AHCA concedes,

that the rule requiring compliance with ADA standards was not adopted until a

year after this application was filed. In addition, ADA compliance is required

for new construction, not redecorating.

28. AHCA also criticized UCH for omiting the cost of relocating 10

medical/surgical beds, after the conversion of 20 of the existing 30 beds to CMR

beds. UCH asserts that the conversion or relocation of the 10 beds is properly

an expense item in the project which would utilize the 10 beds and is included

in other pending CON applications for difference services. Other CON projects

however, are not certain to be approved. If none are, UCH's expert planner

testified that the 10 beds will be located in a general surgical area which is

being redecorated. UCH also maintains that as long as it can bring the CMR beds

on line within the total project costs within the application, it should be

allowed to do so, even if that involves shifting amounts among the various

expense items. AHCA has not estimated the cost of relocating the 10 beds, nor

contradicted UCH's alternative plans for covering that cost. UCH's projected

total project costs are, therefore, accepted as reasonable.

29. AHCA agrees that UCH could profitably operate a CMR unit,

particularly, as proposed to provide stroke and orthopedic services to medicare

patients. When UCH operated an 18-bed unit, occupancy ranged from 77 percent to

84 percent, with 80 to 85 percent of the patients transferring from UCH acute

care beds. Projected charges, deductions from revenue, payor mix, and expenses

are reasonable.

30. AHCA did not dispute UCH's assertions that its proposal is the most

cost-effective alternative for increasing district CMR beds, because no other

provider could initiate such services without substantial construction costs,

and that utilization of CMR beds is increasing.

ADDITIONAL CON CRITERIA AND CMR PROGRAM REQUIREMENTS

31. UCH, as acknowledged by AHCA, has a history of providing quality care

and is accredited by the Joint Commission on Hospital Accreditation.

32. UCH has a staff physiatrist to serve as CMR Medical Director. The

types of therapists needed to provide a coordinated multidisciplinary approach

to rehabilitation are already on staff at UCH. The staffing and renovations of

the wing in the late 1980's indicate that UCH will meet the requirements for

CARF accreditation.

33. UCH does not propose to offer CMR services as a joint venture with any

other health care facility, nor does it propose to offer a service which is not

available in adjacent districts. In fact, AHCA notes that District V providers

had occupancy rates of 53.31 percent for 1990-1991. The agency's rule, however,

places at issue the historic, current and projected population conditions in the

Department service district by age and sex group.

CONCLUSIONS OF LAW

34. The Division of Administrative Hearings has jurisdiction over this

matter. Subsection 408.039(5), Florida Statutes.

35. The applicant has the burden of establishing entitlement to a CON as

the result of balanced consideration of the statutory and rule criteria. Balsam

v. Department of Health and Rehabilitative Services, 486 So.2d 1341 (Fla. 1st

DCA 1986), and Collier Medical Center Inc. v. Department of Health and

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

36. In substantial portion, AHCA's position that the UCH application

should be denied is based on the absence of numeric need, even under its newly

adopted methodology, and on the prior denial of a virtually identical UCH

application.

37. The prior UCH application was considered in University Community

Hospital vs. Department of Health and Rehabilitative Services, 14 FALR 1899 (HRS

Final Order 4/15/92). UCH proposed to convert 20 acute care beds to 20 CMR beds

for approximately $617,674. The hearing officer in that case found, among other

virtually similar facts, the following distinguishable facts:

UCH did not disclose in its application the

capital budget items reflected in its 1990-91

capital equipment budget.

* * *

25. Neither applicant has documented that

existing providers who concentrate in the

treatment of rehabilitation patients are not

currently meeting the needs of the community,

in order to be entitled to the third [local

health plan] preference.

* * *

The projected costs, however, are

predicated on an unproven assumption that the

space intended to house the CMR unit has

already been renovated for rehabilitation

services and that no additional dollars are

required to be spent. Because UCH did not

demonstrate that the space, as currently

designed, is adequate to accommodate a 20-bed

CMR unit, UCH has not shown that its

projected costs are reasonable. UCH may have

to redesign its CMR unit to comply with CARF

standards, thereby incurring additional,

unanticipated costs.

* * *

47. Tampa General presented credible

evidence that a CMR program at UCH would take

107 patients from Tampa General in its first

year of operation alone, assuming UCH attains

its projected occupancy, resulting in a loss

to Tampa General of nearly $1.8 million.

* * *

61. Neither applicant addressed unique

incidence or prevalence in the district as

required by Subparagraph (2)(b)1 of the rule.

Instead, UCH used national incidence rates

and applied them to the population of

District VI.

* * *

and,

73. In summary, the applicants meet very

few of the factors, standards and criteria of

Rule 10-5.039, F.A.C. Those few factors do

not demonstrate a need for additional CMR

beds in District VI.

38. In this case, there was no allegation that UCH did not disclose a

complete list of its capital projects planned, pending, approved or underway.

There was creditable evidence that more CMR beds will result in greater

utilization of the service. There was no evidence to dispute UCH's assertion

that it can become CARF accredited within the projected project costs.

39. No evidence was presented that Tampa General will be impacted

adversely by the establishment of CMR services at UCH.

40. UCH demonstrated, using district usage rates, that a need exists in

the district for additional CMR beds.

41. In this case, on balance, the evidence supports the approval of the

UCH application to meet a need for additional CMR beds in District VI.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is

RECOMMENDED that a Final Order be entered issuing Certificate of Need No.

6936 to University Community Hospital to convert 20 medical/surgical acute care

beds to 20 comprehensive medical rehabilitation beds in District VI.

DONE and ENTERED this 19th day of October, 1993, at Tallahassee, Florida.

___________________________________

ELEANOR M. HUNTER

Hearing Officer

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

[phone]

Filed with the Clerk of the

Division of Administrative Hearings

this 19th day of October, 1993.

APPENDIX TO CASE NO. 92-5107

University Community Hospital

1. Accepted in Findings of Fact 1 and 3.

2. Accepted in Finding of Fact 1.

3. Accepted in Finding of Fact 4.

4. Accepted in Finding of Fact 5.

5. Accepted in Finding of Fact 5.

6. Accepted in Finding of Fact 4.

7. Accepted in Findings of Fact 1 and 5.

8. Accepted in Finding of Fact 29.

9. Accepted in Finding of Fact 29.

10. Accepted in Finding of Fact 6.

11. Accepted in Preliminary Statement.

12. Accepted in Preliminary Statement.

13. Accepted in Finding of Fact 17.

14. Accepted in Finding of Fact 18.

15. Accepted in Finding of Fact 18.

16. Accepted in Finding of Fact 18.

17. Accepted in or subordinate to Finding of Fact 19.

18. Subordinate to Finding of Fact 19.

19. Accepted in Findings of Fact 20 through 24.

20. Accepted in Finding of Fact 16.

21. Subordinate to Finding of Fact 21.

22. Subordinate to Finding of Fact 21.

23. Accepted in Finding of Fact 29.

24. Accepted in part and rejected in part in Findings of

Fact 6-16.

25. Accepted in Finding of Fact 8.

26. Accepted in Finding of Fact 20.

27. Accepted in Finding of Fact 20.

28. Accepted in Finding of Fact 21.

29. Subordinate to Finding of Fact 21.

30. Accepted in Finding of Fact 22.

31. Accepted in Finding of Fact 22.

32. Accepted in Finding of Fact 24.

33. Subordinate to Finding of Fact 24.

34. Subordinate to Finding of Fact 24.

35. Subordinate to Finding of Fact 24.

36. Accepted in Finding of Fact 23.

37. Subordinate to Finding of Fact 23.

38. Subordinate to Finding of Fact 23.

39. Subordinate to Finding of Fact 23.

40. Subordinate to Finding of Fact 23.

41. Subordinate to Finding of Fact 23.

42. Accepted in Finding of Fact 23.

43. Subordinate to Finding of Fact 23.

44. Subordinate to Finding of Fact 23.

45. Subordinate to Finding of Fact 23.

46. Subordinate to Finding of Fact 23.

47. Subordinate to Finding of Fact 24.

48. Subordinate to Finding of Fact 24.

49. Subordinate to Finding of Fact 24.

50. Subordinate to Finding of Fact 24.

51. Accepted in Findings of Fact 7 and 27.

52. Accepted in Finding of Fact 29.

53. Accepted in Finding of Fact 29.

54. Accepted in Finding of Fact 29.

55. Accepted in Finding of Fact 30.

56. Accepted in Finding of Fact 27.

57. Accepted in Findings of Fact 26 and 28.

58. Subordinate to Finding of Fact 27.

59. Accepted in Finding of Fact 27.

60. Accepted in Finding of Fact 27.

61. Accepted in Finding of Fact 27.

62. Accepted in Findings of Fact 31 and 32.

63. Subordinate to Finding of Fact 1.

64. Accepted in Findings of Fact 27 and 32.

65. Subordinate to Finding of Fact 27.

66. Subordinate to Finding of Fact 30.

67. Subordinate to Finding of Fact 30.

68. Accepted.

69. Accepted in Finding of Fact 32.

70. Accepted and subordinate to Finding of Fact 1.

Agency For Health Care Administration

1. Accepted in Findings of Fact 1 and 3.

2. Accepted in Findings of Fact 1 and 3.

3. Accepted in Finding of Fact 1.

4. Accepted in Finding of Fact 4.

5. Accepted in Finding of Fact 5.

6. Accepted in Finding of Fact 6.

7. Accepted in Findings of Fact 1 and 4.

8. Accepted in Findings of Fact 26 and 28.

9. Accepted in Finding of Fact 27.

10. Accepted in Finding of Fact 32.

11. Accepted in Finding of Fact 1.

12. Accepted in Finding of Fact 29.

13. Accepted in Finding of Fact 5.

14. Accepted in Finding of Fact 6.

15. Accepted in Finding of Fact 7.

16. Accepted in Finding of Fact 8.

17. Accepted in Finding of Fact 9.

18. Accepted in Finding of Fact 10.

19. Rejected in Finding of Fact 11.

20. Accepted in Finding of Fact 12.

21. Rejected in Finding of Fact 16.

22. Accepted in Finding of Fact 13.

23. Accepted in Finding of Fact 14.

24. Rejected in Findings of Fact 20 and 22.

25. Accepted in Finding of Fact 15.

26. Subordinate to Finding of Fact 32.

27. Accepted in Finding of Fact 19.

28. Accepted in Finding of Fact 21.

29. Rejected in Findings of Fact 20-23.

30. Accepted in Finding of Fact 17.

31. Accepted in Findings of Fact 8, 17 and 19.

32. Accepted in Finding of Fact 17.

33. Accepted in Finding of Fact 16.

34. Accepted in Finding of Fact 16.

35. Rejected in Findings of Fact 20-23.

36. Rejected in Findings of Fact 20-23.

37. Accepted in Finding of Fact 18.

38. Rejected in Finding of Fact 24.

39. Accepted in Finding of Fact 18.

40. Accepted in Finding of Fact 25.

41. Rejected in Finding of Fact 24.

42. Accepted in Finding of Fact 16.

43. Accepted in relevant part in Finding of Fact 21.

44. Accepted in Finding of Fact 16.

45. Conclusion Rejected in Findings of Fact 20-23 and 29.

46. Accepted in Finding of Fact 16.

47. Accepted in Finding of Fact 32.

48. Accepted in Finding of Fact 20.

49. Accepted in Finding of Fact 20.

50. Rejected in Finding of Fact 29.

51. Accepted in Findings of Fact 29 and 4.

52. Rejected in Finding of Fact 29.

53. Accepted in Finding of Fact 21.

54. Subordinate to Findings of Fact 21-24.

55. Accepted in Findings of Fact 21-24.

56. Accepted in Findings of Fact 21-24.

57. Subordinate to Finding of Fact 24, and Accepted in Finding

of Fact 33.

58. Accepted in Findings of Fact 4, 21 and 32.

59. Rejected in Findings of Fact 4, 21, and 32.

60. Subordinate to Finding of Fact 21.

61. Subordinate to Finding of Fact 21.

62. Accepted in Finding of Fact 33.

63. Accepted in Finding of Fact 33.

64. Accepted in Finding of Fact 9.

65. Accepted in Finding of Fact 9.

66. Subordinate to Finding of Fact 29.

67. Subordinate to Finding of Fact 29.

68. Subordinate to Finding of Fact 29.

69. Accepted in Finding of Fact 29.

70. Rejected in relevant part in Findings of Fact 27 and 28.

71. Rejected in Findings of Fact 27.

72. Subordinate to Finding of Fact 21.

73. Accepted in Finding of Fact 23.

74. Rejected in Finding of Fact 27.

75. Accepted in Finding of Fact 29.

76. Issue not reached. See Finding of Fact 27.

78. Issue not reached. See Finding of Fact 27.

79. Issue not reached. See Finding of Fact 27.

80. Accepted in relevant part in Finding of Fact 28.

81. Subordinate to Finding of Fact 29.

82. Rejected in Findings of Fact in 21-24.

83. Rejected in Finding of Fact 23.

84. Accepted, except last sentence in Findings of Fact 21-24.

COPIES FURNISHED:

Sam Power, Agency Clerk

Agency for Health Care Administration

The Atrium, Suite 301

325 John Knox Road

Tallahassee, Florida 32303

Lesley Mendelson, Senior Attorney

Agency for Health Care Administration

325 John Knox Road, Suite 301

Tallahassee, Florida 32303-4131

Cynthia S. Tunnicliff, Esquire

Post Office Box 190

Tallahassee, Florida 32302

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

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

Order. All agencies allow each party at least 10 days in which to submit

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

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

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

to this Recommended Order. Any exceptions to this Recommended Order should be

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