96-004058CON Home Health Care Services, D/B/A Southmed Health Care vs. Agency For Health Care Administration Status: Closed Recommended Order on Friday, June 27, 1997.

Summary: Two applications in District three for Medicare certified home health agency Certificate Of Needs (CONs) are unique and should be granted.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

HOME HEALTH CARE SERVICES, d/b/a )

SOUTHMED HEALTH CARE, )

)

Petitioner, )

)

vs. ) Case Nos. 96-4058

) 96-4060

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

__________________________________)

RECOMMENDED ORDER

Pursuant to notice, a final hearing was conducted in this

matter by David M. Maloney, Administrative Law Judge of the

Division of Administrative Hearings, on January 8, 9 and 10,

1997, in Tallahassee, Florida.

APPEARANCES

For Petitioner Cynthia S. Tunnicliff, Esquire

Home Health Care Pennington Culpepper Moore

Services d/b/a Wilkinson Dunbar and Dunlap, P.A.

SouthMed Health Care Post Office Box 10095

Tallahassee, Florida 32303-2095

For Petitioner Theodore E. Mack, Esquire

Lake City Nursing Cobb Cole and Bell

Homes, Inc. 131 North Gadsden Street

Tallahassee, Florida 32301

For Respondent Richard Patterson, Esquire

Agency for Health Agency for Health Care

Care Administration Administration

2727 Mah an Drive, Suite 3431

Tallahassee, Florida 32308-5403

STATEMENT OF THE ISSUES

Whether there is need for any new Medicare certified home

health agencies in AHCA District III, and if so, whether the

applications filed with the Agency by the two petitioners in this

case meet criteria for the award of a certificate of need?

PRELIMINARY STATEMENT

On August 28, 1996, the Division of Administrative Hearings

received notices from the Agency for Health Care Administration

advising that the Agency had received requests for a formal

administrative hearing from four parties, all applicants for home

health agency certificates of need in AHCA District III whose

applications had been denied preliminarily: A Healthcare

Specialists, Inc., Home Health Care Services d/b/a SouthMed

Health Care, Home Health Integrated Health Services of Florida,

Inc., and Lake City Nursing Homes, Inc. The Agency requested the

Division of Administrative Hearings to assign the matters to a

Hearing Officer (Administrative Law Judge) and to conduct all

proceedings necessary under law, including submission of a

recommended order to the agency.

Attached to each of the notices was a Petition for Formal

Administrative Hearing and a Notice of Related Petitions

indicating that the four petitions were, indeed, related. The

four cases were given Case Nos. 96-4057, 96-4058, 96-4059 and

96-4060, assigned to Judge Eleanor M. Hunter, and consolidated.

Following issuance of a notice of hearing, a continuance,

and a second notice of hearing, the case proceeded to hearing the

first full week of January, 1997. In the interim two of the

petitioners filed voluntary dismissals (leaving only Case

Nos. 96-4059 and 96-4060 to be decided) and the case was

transferred to the undersigned.

At final hearing, Lake City Nursing Homes, Inc., ("Lake

City") called three witnesses: Joseph D. Mitchell, expert in

health care accounting; Michael Foxworthy, expert in health care

management; and, Jim White, expert in health care planning and

CON review. Lake City's Exhibit 1, consisting of its entire CON

application, was admitted into evidence.

Home Health Care Services ("HHCS,") called three witnesses:

Lois Adams, expert in health care management; Darryl Weiner,

expert in health care finance; and Sharon Gordon-Girvin, expert

in health care planning. HHCS offered five exhibits, all of

which were admitted into evidence.

The Agency called two witnesses: Roger Bell, expert in

health care finance; and Cheryl Clark, expert in CON review. The

Agency offered six exhibits, all admitted into evidence.

Proposed recommended orders were submitted by all three

parties on March 21, 1997.

FINDINGS OF FACT

The Parties

1. Home Health Care Services d/b/a SouthMed Health Care, if

operational, will be part of the HHCS Health Group. The group

includes a number of interrelated medical corporations under the

HHCS umbrella. Among them are these: the Cystic Fibrosis

Pharmacy, Inc.; the HHCS Pharmacy; the Special Pulmonary Care

Center; the HHCS Research Institute, Inc.; and the Center for

Environmental and Industrial Medicine, Inc. HHCS also operates

home health care agencies in Melbourne, Rockledge, Tampa, Port

Charlotte, and Sarasota.

2. Lake City Nursing Homes, Inc., is the owner and licensee

of Lake City Extended Care Center, a 60-bed nursing facility in

Columbia County, Florida. It is a provider currently of home

health care for Medicaid recipients and private payors though its

licensed home health agency located adjacent to the nursing home.

By the CON application at issue in this proceeding, Lake City

proposes to provide skilled nursing home based Medicare certified

home health agency services as well.

3. The Agency for Health Care Administration is the "single

state agency [designated by statute] to issue . . . or deny

certificates of need . . . in accordance with the district plans,

the statewide health plan and present and future federal and

state statutes." Section 408.034(1), Florida Statutes.

Service Planning Area and Existing Providers

4. AHCA District III consists of sixteen counties:

Hamilton, Suwannee, Lafayette, Dixie, Columbia, Gilchrist, Levy,

Union, Bradford, Putnam, Alachua, Marion, Citrus, Hernando,

Sumter, and Lake.

5. At the time of the submission of the applications at

issue in this proceeding, there were twenty-nine existing

Medicare certified home health agencies in District III.

6. HHCS proposes to target a group of patients none of the

other existing providers presently target. In another approach,

Lake City proposes a nursing-home based, Medicare certified home

health agency. Other than Lake City's existing non-Medicare

certified agency, none of the existing providers are nursing-home

based. In relation to the existing providers, therefore, Lake

City and HHCS propose unique opportunities for home health care

services in District III.

HHCS' Application

7. HHCS' application is targeted to a group of patients in

District III not presently receiving services which rise to the

level of their need. The group consists of post-transplant

patients and patients with cystic fibrosis, chronic obstructive

pulmonary disease ("COPD"), and diabetes.

8. Targeting this group does not diminish HHCS' intent to

provide home health care to others in District III in need. HHCS

has agreed to condition the granting of the CON on providing 8

percent Medicaid and 2 percent charity care with no limit on the

number of Medicaid patients it will serve.

9. HHCS offers to provide services not commonly provided by

other home health agencies. Among them are blood transfusions,

home x-ray, on-line EKG communication with physician, organ

transplantation support and care, Picasso system

telecommunications with physician, and high-tech pharmacy service

such as intravenous/infusion services, aerosolized pentamidine

therapy, and complete HIV home care.

10. In providing these sophisticated services, HHCS will

use an integrated team approach to home health care involving

various professionals in health care and health management.

Lake City's Application

11. If Lake City's applic ation were granted, it would make

Lake City the fourth home health agency in Lake County and the

only home health agency in District III to be nursing-home based.

12. By combining a Medicare certified home health agency

with its existing nursing home, Lake City will improve the case

management of its patients because such an arrangement offers

vertical integration within a continuum of care. Vertical

integration within a continuum of care promotes stability of

personnel and providers who work with the patients. In turn,

this organizational method provides potential for improving

recovery from illness and higher quality of management of the

patient and the patient's illness.

Need Projections

13. The Agency's methodology for determining need for home

health agencies was declared invalid in 1993. At present, there

is no Agency rule containing a home health agency need

methodology.

14. In the absence of a need methodology by rule, the

applicants took different approaches to projecting need.

15. HHCS pr ojected need based upon previous studies of

efficient agency size.

16. HHCS identified four groups of Medicare patients (AIDS,

COPD, cystic fibrosis, and diabetes) who, either because of age

or disability, are chronic or long-term users of home health care

services. HHCS looked at hospital discharges for those four

categories to determine post-hospital placement. About an equal

number of patients were referred to long-term facilities as were

being referred to home health agencies. HHCS' application is

geared to steering patients out of more expensive long-term care

facilities and into care at home.

17. Lake County has a use rate for home health higher than

that of all of District III. Its use rate is also higher than

the State's as a whole. Over a three-year period, home health

visits in District III grew by 16 percent, whereas visits

statewide grew by only 4 percent.

18. Lake County uses home health services and continues to

use them at a very high rate. Additional services are needed in

order to sustain and meet the demand within the county and the

District as a whole. Previous studies, moreover, have shown that

all economies of scale are realized at around 30,000 visits per

year. HHCS used 30,000 visits per year as an appropriate agency

size to yield a need in the District for at least five new

agencies.

19. With the modification of a lower growth rate to make it

more conservative, Lake City, on the other hand, utilized a need

methodology put to use by a successful Medicare certified home

health agency applicant for five Medicare certified home health

agency CONs in the prior batching cycle.

20. The Lake City methodolgy took the population of seniors

(age 65 and over) in the district and projected that population

forward through 1998 based on state population data. It then

calculated the percentage of increase in population of seniors

and the total number of visits provided in the district and

projected the percent of increase in visits from 1991 through

1994 forward on through 1998. Lake City projected its increase

in total visits utilizing an 11.5 percent growth rate in the

number of visits which is conservative considering that the

average growth rate per year from 1991 to 1994 was 31.7 percent.

Lake City also identified a yearly increase of more than 20

percent in the rate of use of home health services due to the

emphasis on managed care and less costly health care services.

Inflating a conservative increase in the use rate of 20 percent

forward, Lake City projected the number of visits that would be

provided by existing agencies and subtracted that number from the

total number of projected visits, leaving a total number of

unserved visits. Dividing the number of unserved visits by the

average agency size in District III, Lake City came up with a net

need of 9.62 agencies in the horizon year of 1997.

21. The methodologies of both HHCS and Lake City are fair

and reasonable health planning methodologies.

22. Lacking a need methodology, the Agency set forth eight

criteria it suggested should be addressed in applications for

Medicare certified home health agency CONs. These policies

relate generally to access and require the showing of some type

of access problem. Normally, however, need should not be

determined on the basis of access problems alone.

23. Both applicants demonstrated District III's need in the

planning horizon year for more than two agencies, the number of

applicants in this proceeding. There is, therefore, a need for

at least two more Medicare certified home health agencies in

District III.

State and Local Health Plans

24. The HHCS proposal is supported by the preferences in

the District Health Plan. HHCS is an exemplary provider of care

for persons with AIDS and it has committed to Medicaid and

indigent care in excess of that suggested by the plan. HHCS will

provide more than the full range of services suggested by the

plan.

25. For the same reasons it meets the preferences in the

local plan, HHCS' application is supported by the preferences in

the State Health Plan. In addition to those reasons, the

application complies with the State Health Plan preferences for

an applicant that proposes to serve counties presently

underserved by home health care agencies; will provide consumer

satisfaction data to the Agency; and has a comprehensive quality

assurance program and is proposing to be accredited by the Joint

Commission on Accreditation of Healthcare Organizations

("JCAHO").

26. Lake City's application is also supported by

preferences in the District Health Plan. It has a history of

providing a high percentage of Medicaid patient days at its

nursing facility. This history backs up its commitment to

provide a minimum of 1 percent annual visits to indigent care and

5 percent of annual visits to care of Medicaid patients, a

commitment evidenced by its willingness to condition the grant of

its CON on the percentages of annual visits it promises to

indigent and Medicaid patients.

27. Likewise, Lake City 's application is supported by

preferences in the State Health Plan. It has agreed to condition

its CON on providing care to AIDS patients. It will provide the

entire range of services usually provided by a home health care

agency. It is willing to condition its CON on cooperation with

data collection efforts. Finally, it is willing to condition the

grant of its CON on the provision of a comprehensive quality

assurance program as well accreditation by the JCAHO.

Availability, Access, Appropriateness and

Adequacy of Like and Existing Health Care Services

28. HHCS' application complies with the statutory

requirements of Section 408.035(1)(b), Florida Statutes, in that

it increases the availability and access to home health care in

the District.

29. HHCS will offer programs and services which presently

are not readily available in District III. This will increase

the availability of these services to the patients of the

District and, in particular, to the patients of Lake County.

Thus, geographic access is enhanced.

30. HHCS' application also enhances acce ss for those

without means to gain access to home health care through its

commitment to indigent care.

31. It improves, too, the adequacy of services in the

District through its targeting of a group presently underserved

in the District.

32. HHCS' proposal meets the requirements of the health

care access criteria contained in Rule 59C-1.030(2)(a)(b) and

(d), Florida Administrative Code. It provides services to all

those who need care and participates in the Medicare and Medicaid

programs. HHCS does not discriminate on the basis of race,

ethnicity, or gender.

33. Because Lake City is not targeting an underserved group

in the manner of HHCS, its application addresses the issues of

"availability and access" somewhat differently. To the extent

there is a need for new providers of home health care, granting

Lake City's CON will provide better availability and access to

those in need of home health services. Likewise, Lake City's

willingness to condition its application on service to AIDS,

indigent and Medicaid patients will only improve availability and

access to home health care services in the district

Quality of Care

34. HHCS conducts mock accreditation surveys to determine

whether it is meeting the appropriate standards for quality of

care. HHCS has an outside advisory board that does performance

improvement and quality assurance review. There is also a

utilization review committee and each office has full time

quality assurance staff, quality management meetings, and

quarterly reports to the Board of Directors.

35. HHCS' team approach will enhance the quality of care as

well as being cost effective. Its approach to treatment of HIV

patients won for HHCS a contract with the Orange County Public

Health Unit to provide complete HIV service to its patients.

36. HHCS also measures patient satisfaction with services.

Every patient is notified 48 hours after admission to the agency

to make sure they were informed of precisely what to expect from

the agency. Patients are contacted 30 days after admission and

given an evaluation form. Survey forms are also sent out upon

discharge and three months after discharge.

37. The other home health agencies operated by HHCS are

accredited with commendation by JCAHO and HHCS intends to seek

JCAHO accreditation if granted a CON.

38. The Lake City facility is managed by HealthPrime, a

long term care management company which manages facilities for

itself and others and which has been successful in improving

distressed facilities. Since the commencement of its management

of the Lake City facility, the facility has been recommended for

a superior rating.

39. HealthPrime has shown through its operation of the Lake

City facility and other nursing homes in Florida, all of which

have superior ratings, that it has the ability to provide quality

of care.

40. In addition, HealthPrime, which will actually operate

the home health agency, has experience operating three other

nursing home based, home health agencies.

41. HealthPrime will use its quality assurance prog rams

already in place in its other home health agencies and will seek

JCAHO accreditation of the Lake City agency, if the CON is

granted.

42. To show its commitment to assuring quality of care,

Lake City is willing to condition its CON on the understanding

that it will not contract with other non-Medicare certified home

health agencies to provide any of its services.

Availability and Adequacy of Alternatives

43. There is no adequate alternative to the HHCS proposal

because of the applicant's targeting of the management of certain

chronic illnesses. HHCS sees some of the targeted clients for

management of cystic fibrosis already, but it is limited in its

ability to serve these patients effectively without a physical

presence in the District. For these patients to receive the full

complement of home health care services HHCS is capable of

rendering, there is no alternative save approval of its

application.

Economies and Improvements from Joint or Shared Services

44. There are nine related companies with in the HHCS Health

Group. They include pharmacies which can deliver medications

directly to the patient and can provide consultation with a

doctor of pharmacy. This ensures compliance and dramatically

increases therapeutic outcomes.

45. Joint companies typically provide for economies and

efficiencies and lead to the most cost-effective service.

46. Lake City's proposal to operate a nursing home based,

home health agency not only offers a continuum of care for the

patient but also provides fiscal economies to the agency as well

as the Medicare program.

47. By providing skilled, nursing-facility based Medicare-

certified, home health care, the Lake City facility can broaden

its community base and provide cost-efficient services to the

community.

48. Under the arrangement proposed by Lake City, the home

health agency, in practice, becomes a department of the nursing

facility, providing a continuum of care and individual case

management for the patient. Through case management, Lake City

can help an individual through the various levels of care

available.

49. Case management helps the individual gain access to

health care, making the process easier and less stressful. Case

management poses potentials for containing cost and providing the

best quality of care at the least cost.

Financial Feasibility

i. Short Term

50. HHCS has projected the cost of its project at $92,392.

The projection is based on historical information and actual

vendors used by HHCS. Some of the expenditures, such as

consultants and attorney's fees, have already been spent.

51. HHCS intends to fund the $92,000 projected costs of the

project through cash from operations and does not intend to seek

any bank financing. If there is a need for financing, it is

available as evidenced by the letter from the bank contained in

the application. The letter is typical of letters banks issue

when projects are merely proposed. The Agency has approved

projects with similar letters of interest to support the capital

requirements of a project.

52. HHCS also has a line of credit for $600,000 and an

equipment loan of $196,000, of which only $66,000 has been used.

The line of credit was reduced by funds from operations from

$125,000 on December 31, 1994, to $12,000 on April 25, 1995.

53. Schedule 2 in the HHCS application lists other planned

projects which require capital expenditures. These projects

would be funded by a line of credit, assistance from the bank,

and internal operations.

54. HHCS' proposal is financially feasible in the short

term. HHCS has the ability to secure funds necessary to

capitalize the project and to secure any necessary working

capital during the first year of operation.

55. HHCS has demonstrated its ability to fund this project

and all the projects on Schedule 2 in its pro forma sheet.

Schedule 8A shows what would happen if all the projects listed on

Schedule 2 actually occurred and what would be the financial

impact on HHCS. Even if all the projects were completed, the

cash available from operations is sufficient to fund the project.

56. As for Lake City, AHCA raised questions about its weak

financial status as a developmental stage corporation. But at

hearing, AHCA acknowledged that Lake City would be financially

feasible in the short term.

57. While Lake City is a developmental stage company with

limited cash investment, it is a heavy Medicaid provider. There

are disincentives for such providers to keep large amounts of

cash in equity. Lack of equity causes AHCA legitimate concerns.

The concerns are dispelled by the personal guarantee by the

owners of the company of the company's debt since the owners have

sufficient assets to support their guarantees.

58. In analyzing the financial strength of a nursing home

that provides a high percentage of Medicaid-reimbursed care, it

is necessary to determine whether the facility's fixed costs are

covered by Medicaid payments and whether the facility has an

adequate patient census. In the case of Lake City, both of these

factors are positive.

59. In addit ion, HealthPrime has made available a $200,000

loan to Lake City for this project. The loan commitment, by

itself, is more than sufficient to cover the $77,014 start up

cost of the Lake City proposed project.

ii. Long Term

60. HHCS' proposal demonstrated long term financial

feasibility. The applicant's projections are conservative and

the volume projections are easily achievable given the historical

experience of HHCS and District III.

61. The projected revenues contained on HHCS' Schedule 7

and the volume projections utilized in Schedule 5 are reasonable.

AHCA found the volume projections to be achievable.

62. The projected expenses for the proposed project are

contained on HHCS' Schedule 8B. While AHCA criticized the format

of this schedule, it concedes that it was not unauthorized.

Direct patient care expense and other expenses can be determined

to allow for a review as to reasonableness. Schedule 8B is based

upon historical expense information; it contains all of the

necessary expense items and is reasonable.

63. AHCA similarly found that since HHCS' projections were

reasonable for a new home health agency, the conclusion of

financial feasibility in the long-term is reasonable.

64. Lake City's assumptions in its financial projections

were based on actual experience in the operation of similar

skilled nursing facility based home health agencies, as well as

experience of other home health agencies in their first two years

of operation. The reasonableness of Lake City's financial and

operational projections were undisputed at hearing and AHCA's

financial expert acknowledged that the proposed project would be

financially feasible in the long term

Resource Availability

65. Neither HHCS nor Lake City will have any problem in

hiring sufficient personnel for their agencies.

Efficiency

66. HHCS' specialty team approach to home health results in

fewer total visits and better outcomes at lower cost. HHCS

operates a highly effective, cost efficient agency.

67. As for the efficiency of Lake City's proposal, skilled

nursing home-based Medicare certified home health agencies are

specifically recognized by the Federal Medicare program in their

cost reports. Home health costs are filed as a part of the

nursing home cost report and there is an allocation of the

nursing home's cost to the home health agency.

68. A joint nursing home/home health agency operation

benefits both the provider and the Medicare program through cost

savings. In fact, HealthPrime has found the efficiencies of a

skilled nursing home-based Medicare certified home health agency

to be great enough to allow the home health agency to operate

under the Medicare reimbursement cap.

Projects Impact on Costs

69. The approval of additional home health agencies in

District III will foster competition among existing providers.

HHCS is cost effective with a projected cost per visit of $67.55.

Utilization of its related companies will not only promote a

continuum of care but will also lead to cost effectiveness.

70. Lake City's projected Medicare rate for 1997 will be

substantially less than the District III average 1994 rates of

existing home health agencies. This provides a cost savings to

the state since it helps reduce Medicaid costs as well.

CONCLUSIONS OF LAW

71. The Division of Administrative Hearings has

jurisdiction over the subject matter and the parties. Sections

120.57(1) and 408.039(5), Florida Statutes.

72. The applicants have the burden of demonstrating that

their applications should be granted. Boca Raton Artificial

Kidney Center v. Department of Health and Rehabilitative

Services , 475 So. 2d 260 (Fla. 1st DCA 1985). The award of a

Certificate of Need must be based on a balanced consideration of

statutory and rule criteria. Department of Health and

Rehabilitative Services v. Johnson Home Health Care, Inc ., 447

So. 2d 361 (Fla. 1 st DCA 1994); Balsam v. Department of Health

and Rehabilitative Services , 486 So. 2d 1341 (Fla. 1 st DCA 1988).

The weight to be given each criterion is not fixed but varies

depending on the facts of each case. Collier Medical Center,

Inc., v. State, Department of Health and Rehabilitative Services ,

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

73. The Agency for Health Care Administration argues

primarily that the applications fail for two reasons: first,

neither demonstrated that there was a need for the proposal; and

second, neither demonstrated a problem with availability, quality

of care or accessibility of the existing Medicare-certified home

health agencies in the district or that existing agencies are

over-utilized and experiencing volume constraints.

74. To the contrary, both applicants, using fair and

reasonable methodologies in the absence of a methodology

sanctioned by rule, established that there was a need for at

least two more home health agencies in District III.

75. As for access to well-utilized existing providers that

provide good quality of care, AHCA is right in the case of Lake

City; this applicant did not prove that there is a problem with

access to the services it hopes to offer in District III. But

there is no AHCA rule that declares that the paramount

consideration in cases involving applications for Medicare

certified home health agencies is whether there is a problem with

access to existing providers. Furthermore, both parties proved

that access to residents of District III in need of home health

services will improve if these two Medicare certified home health

agency CONs are granted.

76. As for the accessibility issue in relation to HHCS,

HHCS proved that accessibility to needed home health services

will improve for a part of the discrete group targeted by its

application: patients with cystic fibrosis. For the others

targeted by HHCS, post-transplant patients, and patients with

chronic pulmonary disease and diabetes, granting HHCS a CON will

increase the access of these patients to the sophisticated

services HHCS has to offer in a home health setting.

77. Just as granting HHCS' application will improve patient

care of home health patients in District III, so will granting

Lake City's application because of its uniqueness in District III

as a nursing home based, Medicare certified home health agency.

78. Finally, both applicants, on balance, meet the

applicable and rule and statutory criteria for the granting of

their applications.

RECOMMENDATION

Based on the foregoing findings of fact and conclusions of law,

it is recommended that the Agency for Health Care Administration

grant CON applications 8387 and 8386 filed by Home Health Care

Services d/b/a SouthMed Health Care and Lake City Nursing Homes,

Inc., respectively.

DONE AND ENTERED this 27th day of June, 1997, in

Tallahassee, Leon County, Florida.

___________________________________

DAVID M. MALONEY

Administrative Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

[phone] SUNCOM 278-9675

Fax Filing [phone]

Filed with the Clerk of the

Division of Administrative Hearings

this 27th day of June, 1997.

COPIES FURNISHED:

Cynthia S. Tunnicliff, Esquire

Pennington Culpepper Moore

Wilkinson Dunbar and Dunbar PA

Post Office Box 10095

Tallahassee, Florida 32303-2095

Theodore E. Mack, Esquire

Cobb Cole and Bell

131 North Gadsden Street

Tallahassee, Florida 32301

Richard Patterson, Esquire

Agency for Health Care Administration

Fort Knox Building 3, Suite 3431

2727 Mahan Drive

Tallahassee, Florida 32308-5403

Jerome W. Hoffman, General Counsel

Agency for Health Care Administration

Fort Knox Building 3

2727 Mahan Drive

Tallahassee, Florida 32308-5403

Sam Power, Agency Clerk

Agency for Health Care Administration

Fort Knox Building 3, Suite 3431

2727 Mahan Drive

Tallahassee, Florida 32308-5403

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within 15

days from the date of this recommended order. Any exceptions to

this recommended order must be filed with the agency that will

issue the final order in this case.