96-004067CON Aaction Home Health Care, Inc. vs. Agency For Health Care Administration Status: Closed Recommended Order on Monday, December 22, 1997.

Summary: Two home health agencies should be approved for Certificate of Needs (CONs) based on credible reasonable need methodologies by experts and in absence of agency rule.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

AACTION HOME HEALTH CARE, )

INC., et al ., )

)

Petitioner, )

)

vs. ) Case No. 96-4067

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

___________________________________)

NURSING UNLIMITED 2000, INC., )

)

Petitioner, )

)

vs. ) Case No. 96-4070

)

AGENCY FOR HEALTH CARE )

ADMINISTRATION, )

)

Respondent. )

___________________________________)

RECOMMENDED ORDER

Pursuant to notice, the Division of Administrative Hearings,

by its duly designated Administrative Law Judge, Mary Clark, held

a formal hearing in the above-styled consolidated cases on

October 14 through 16, 1997, in Tallahassee, Florida.

APPEARANCES

For Petitioner Michael Manthei

Aaction Home Broad and Cassel

Health Care, 1130 Broward Financial Center

Inc.: 500 East Broward Boulevard

Fort Lauderdale, Florida 33394

For Petitioner R. David Prescott

Nursing Rutledge, Ecenia, Underwood

Unlimited 2000, Purnell & Hoffman, P.A.

Inc.: Suite 420

215 South Monroe Street

Tallahassee, Florida 32301

For Respondent: Moses E. Williams

Office of the General Counsel

Agency for Health Care Administration

Post Office Box 14229

Tallahassee, Florida 32317-4229

STATEMENT OF THE ISSUES

Whether the applications for certificates of need to

establish Medicare-certified home health agencies filed by

Aaction Home Health Care, Inc. (Aaction) and Nursing Unlimited

2000, Inc. (Nursing Unlimited), on balance, satisfy the

applicable review criteria so as to entitle either or both to

award of a certificate of need.

PRELIMINARY STATEMENT

The Agency for Health Care Administration (AHCA or the

Agency) reviewed and preliminarily denied on July 2, 1996, six

applications for certificates of need (CON) to establish

Medicare-certified home health agencies in AHCA Health Planning

District 11. All six applicants filed petitions for formal

administrative hearings which were referred to the Division of

Administrative Hearings (DOAH) and were consolidated for hearing

as reflected in the above style. Four of the six original

petitioners for a formal administrative hearing voluntarily

dismissed or had dismissed their petitions prior to final

hearing. Remaining for resolution in this proceeding are the CON

applications of Aaction and Nursing Unlimited.

Aaction called as its witness Mark Richardson, expert in

health care planning, home health planning, and numeric need

methodology. Aaction’s exhibits 1-3 and 5 were received in

evidence. Exhibit no. 4, taken under advisement at hearing, is

now received in evidence.

Nursing Unlimited's witnesses were: Aida Salazar-Rebull,

expert in home health care administration and operations; and

Michael L. Schwartz, expert in health care planning, health care

administration, and health care finance. Nursing Unlimited’s

Exhibits 1-6 were received in evidence.

AHCA called as its witness James B. McLemore, Jr., accepted

at the hearing as an expert in health care planning. AHCA’s

Exhibits 1-4 and 7-8 were received in evidence.

The transcript of the proceeding was filed on November 19,

1997, and the parties filed their proposed recommended orders on

December 1, 1997.

As required by a pre-hearing order, the parties filed a

Joint Prehearing Stipulation on September 24, 1997. The Joint

Prehearing Stipulation includes the following statement of those

facts which are admitted and require no proof at hearing:

1. The letters of intent of both Aaction and

Nursing Unlimited are complete, including all

mandatory content items, and were timely filed

with AHCA and the local health council.

2. The CON applications and omissions

responses of both Aaction and Nursing Unlimited

are complete, including all mandatory application

content items, and were timely filed with AHCA and

the local health council.

3. AHCA published no fixed need pool

applicable to this proceeding or these applicants.

4. The applicants each, on balance, satisfy

or meet the preferences of the applicable district

health plan. Section 408.035(1)(a), Florida

Statutes, and Rule 59C-1.030(2)(c), Florida

Administrative Code.

5. The applicants each, on balance, satisfy

or meet the preferences of the state health plan.

Section 408.035(1)(a), Florida Statutes, and Rule

59C-1.030(2)(c), Florida Administrative Code.

6. The applicants each have a history of

providing quality care and have demonstrated the

ability to provide quality care. Section

408.035(1)(c), Florida Statutes.

7. The applicants each addressed that there

were no reasonable alternatives to its proposed

project. Section 408.035(1)(d), Florida Statutes.

8. Subsections 408.035(1)(e), (f), (g), (j),

(k), (m), and (o); and subsections 408.035(2) and

(3) are not applicable to the home health projects

proposed in this case.

9. The applicants each have the manpower,

management personnel and the financial resources

to establish and operate their respective

projects. Section 408.035(1)(h), Florida

Statutes.

10. Each proposed project is deemed

financially feasible in the immediate and long

term. Section 408.035(1)(i), Florida Statutes.

11. Neither of the proposed projects would

adversely impact the costs of providing health

services proposed by the applicants. Section

408.035(1)(l), Florida Statutes.

12. The applicants each propose to provide

health care services to Medicaid patients and the

medically indigent. Section 408.035(1)(n),

Florida Statutes.

The parties further stipulated that the sole CON review

criteria and issues of fact which remain to be litigated are:

The availability, quality of care,

efficiency, appropriateness, accessibility,

extent of utilization, and adequacy of like

and existing home health care services in

District 11. Section 408.035(1)(b), Florida

Statutes.

The parties also stipulated that the sole issue of law which

remains for determination by the Administrative Law Judge is:

Whether, on balance, the CON application of

Aaction and the CON application of Nursing

Unlimited satisfy the applicable review

criteria so as to entitle each to award of a

CON.

FINDINGS OF FACT

The Applicants

1. Nursing Unlimited 2000, Inc., was formed for the purpose

of obtaining a certificate of need for a Medicare certified home

health agency, and to serve as the entity into which would be

merged certain existing licensed non-Medicare certified home

health agencies in Dade County. Aida Salazar-Rebull is a co-

founder, director, officer, and shareholder of Nursing Unlimited,

and she currently owns, operates, and serves as the administrator

of LTC Professional Consultants, Inc. (LTC), a licensed non-

Medicare certified home health agency in Dade County.

Ms. Salazar will serve as Nursing Unlimited’s administrator, and

after CON approval will merge LTC into Nursing Unlimited and

continue its current operations. Elia Murias is also a co-

founder, director, and shareholder of Nursing Unlimited, and she

currently owns and operates Nursing Love & Care, a licensed non-

Medicare certified home health agency in Dade County. Upon CON

approval, Ms. Murias, a registered nurse, will serve as Nursing

Unlimited’s director of nursing, and will merge the operations of

Nursing Love & Care into Nursing Unlimited.

2. For the past 12 years LTC has provided home health care

services directly to Medicaid and private pay patients, and to

Medicare patients through contracts with Medicare certified

agencies. LTC is accredited by the Joint Commission on

Accreditation of Health Care Organizations (JCAHO), which

accreditation will be transferred to Nursing Unlimited. Since

its inception, the number of patients served by LTC has increased

every year. LTC enjoys an excellent reputation among local

health care providers and patients. LTC’s continual growth over

the past ten years, coupled with the letters of support in the

application, demonstrate a record of providing high quality care

to underserved communities and population subgroups. LTC

currently provides home health services in northwest, west

central, central, and east central Dade County, and as Nursing

Unlimited will serve the same geographic area. LTC places

particular emphasis on its service to underserved population

subgroups such as Hispanics, Haitians, Blacks, low-income

clients, and HIV-positive patients. Nursing Unlimited will

continue to serve those population subgroups.

3. Although approximately 53 percent of the Dade County

population is Latin, only two of the over 30 existing Medicare

certified home health agencies are Latin owned and operated. LTC

and Nursing Love & Care are Latin owned and operated, as would be

Nursing Unlimited. The entire staff of LTC is bilingual, and

some staff are multi-lingual, as would be the staff of Nursing

Unlimited. Approval of Nursing Unlimited's application would

enhance the availability and accessibility of services to the

Latin community.

4. Aaction Home Health Care, Inc. (Aaction), is an existing

home health care agency providing services in Dade County since

approximately 1988. Like Nursing Unlimited, Aaction's target

population is the Hispanic community of Miami and Hialeah.

5. The geographical area which Aaction now serves and will

continue to serve at an enhanced level, if approved, is a low-

income, high crime and low education area. Aaction's success in

those difficult areas is based on its ability to recruit and

retain indigenous staff who know the problems.

6. Over 30 letters of recommendation and support, mostly

from Hispanic physicians, are attached to Aactions's application

and attest to the agency's past and anticipated future service in

the community. Aaction has applied for JCAHO accreditation.

Need Analysis

7. The review of CON applications must be in context with

the criteria set forth in Section 408.035(1), Florida Statutes.

Pursuant to the parties’ prehearing stipulation, both applicants

satisfy all of the applicable review criteria, except this:

The availability, quality of care,

efficiency, appropriateness, accessibility,

extent of utilization, and adequacy of like

and existing home health care services in

District 11. Section 408.035(1)(b), Florida

Statutes.

8. Aaction and Nursing Unlimited both contend there is a

need in District 11 for at least two new or additional Medicare

certified home health agencies. Each asserts that both CON

applications can and should be approved; their respective

applications are not mutually exclusive, and accordingly, they

need not be comparatively reviewed with one another.

9. The focus of the sole remaining criterion at issue,

Subsection 408.035(1)(b), is on existing home health care

providers. As acknowledged by AHCA in its State Agency Action

Report (SAAR), in pure numbers the instant CON application

proposals would increase availability and access in District 11.

10. There is no AHCA rule formula or methodology to

determine a numeric need, nor is there a fixed need pool

applicable to this proceeding. In the absence of an Agency

numeric need rule, the applicants each proposed reasonable need

methodologies within their applications. AHCA did not propose

any need methodology at hearing.

11. AHCA's former home health agency numeric need

methodology rule was invalidated because it was anti-competitive,

understated potential actual need, and failed to consider health

care economics, efficiency and cost containment. Principal

Nursing v. AHCA , DOAH No. 93-5711RX (Final Order January 26,

1994); AHCA v. Principal Nursing Services, Inc. , 650 So. 2d 1113

(Fla. 1st DCA 1995) (Affirmed the Final Order as to the need

methodology, but reversed as to other portions of the rule

unrelated to the issues here).

12. Nursing Unlimited, through Michael Schwartz, applied

the invalidated need methodology to demonstrate that even under

that excessively conservative approach, at least 2 additional

home health agencies are needed in District 11. When the

applications were filed the most current home health visit

utilization data was for calendar year 1994. The number of

visits in 1994 was divided by the age 65 population to determine

a use rate, i.e., the number of home health visits per 100,000

population. The 1994 use rate was applied to the projected age

65 population growth for the three horizon years of 1995-1997, a

projection of 102,039 more patient visits in 1997 than there were

in 1994, based on population growth alone. Next, Mr. Schwartz

determined a cost-efficient agency size (CEAS) by determining

from a review of District 11 existing home health agencies the

point at which the average cost per home health visit was less

than the statewide average cost per visit. In this case, the

result was a CEAS of 34,973, which was divided into the number of

projected new visits in the horizon year 1997 resulting from

population growth alone, which calculation shows a numeric need

for three new home health agencies in District 11. At the time

the CON application was filed there was one approved, but not yet

licensed home health agency, which was subtracted by the

applicant from the net need figure, thus resulting in a net need

for two new agencies.

13. The recent historical data shows that home health care

visits have been on the increase, both in terms of visits per

100,000 population and in terms of visits per patient. The

amount of time spent by patients in the hospital is decreasing,

which translates into increased need by patients for visits from

home health agencies. The need for home health will continue to

increase because it is a cost-effective alternative to nursing

home placement and hospital care. Home health care services are

less costly than care received in hospitals, in nursing homes, or

on an outpatient basis. Thus, allowing greater access to home

health services should reduce the overall cost of health care to

payors, including Medicare.

14. To address this trend Michael Schwartz offered a

realistic, yet still conservative, numeric need projection which

assumes an increased use rate beyond that which is based on

population increase alone. Mr. Schwartz considered the

cumulative increase in visits that occurred over the three-year

period 1991-1994 and projected this forward to the horizon year

of 1997. Although federal Health Care Finance Agency (HCFA) data

suggests that visits will grow nationally at seven percent per

year. Mr. Schwartz assumed only a seven percent increase over

three years, which resulted in a growth of approximately 180,124

visits by 1997, and which divided by the CEAS yields a need for

5.2 new agencies. In hindsight, the conservative nature of this

projection is apparent from a review of utilization data which

has become available since the filing of the CON application.

For example, rather than a growth in visits of 180,000 over the

period 1995-1997, there was an actual increase of over 410,000

visits in 1995 and 1996 alone. Utilization data for 1997 is not

yet available.

15. Aaction presented three separate need methodologies in

its application prepared by Mark Richardson. The first two

methodologies applied a static use rate based on visits in 1994

to the projected population to determine total visits at the

planning horizon. Recognizing that cost efficiencies maximize at

an approximate range between 30,000 and 90,000 visits per year,

Aaction divided the total projected visits by a conservative CEAS

of 50,000. These methodologies yielded a need in District 11 for

two additional home health agencies at the planning horizon.

Using a CEAS of 30,000 visits would yield a need for three

agencies instead of two. AHCA has recently determined that

static use rates are inappropriate. ( Allstar Care, Inc., etc.

vs. AHCA , DOAH No. 96-4064, Final Order November 4, 1997).

Nonetheless, application of over-conservative methodologies in

this case can help counter the agency's unsubstantiated assertion

that many visits are fraudulent or unnecessary.

16. In its third methodology, Aaction assumed more

realistically that home health use rates would continue to

increase as suggested by historic data. In order not to

overstate the potential growth rate, Aaction used a rate equal to

one-half of the 1993-94 actual growth rate. Utilizing a 50,000

visit CEAS, this methodology yields a need of 7 to 9 new home

health agencies in District 11 at the planning horizon. Using a

30,000 visit CEAS yields a net need for over 15 new home health

agencies.

17. Recalculating the need formulas by application of the

now available 1995 and 1996 data, using a growth rate at 50

percent of the actual rate, and a CEAS of 50,000 visits, results

in a need for 7 to 8 new agencies. If the static use rate were

applied, the need would be 5 to 6 new agencies. Application of

Aaction’s initial need methodologies with a static use rate based

on 1996 utilization data yields a need for over 5 new agencies

when a 50,000 visit CEAS is used. If a 30,000 visit CEAS is

utilized, these methodologies yield a net need for 9 new home

health agencies. Applying Aaction’s third methodology (i.e.,

utilization projected to increase at 50 percent of the actual

increase between 1995 and 1996) yields a net need for over 7 or

over 12 new agencies, depending on whether a 50,000 visit or

30,000 visit CEAS is applied.

18. There are other indications of need for additional home

health agencies in District 11. For example, a review of 1996

utilization data reveals that District 11 has only 1.7 home

health agencies per 100,000 population, which is the lowest ratio

of any district in the state. The average of all districts is

2.4 home health agencies per 100,000 population.

19. Both applicants proposed fair and reasonable need

methodologies which demonstrate a need in District 11 for at

least 2 additional home health agencies, and potentially more.

There is, therefore, a need for at least 2 more Medicare-

certified home health agencies in District 11.

20. Approval of both applications will increase the

availability and accessibility of home health services in the

proposed service areas within Dade County. Home health services

are typically delivered in close proximity to the location of the

agency and providers. Nursing Unlimited’s agency location is in

the center of a large Latin and Haitian population, with the

nearest Medicare certified home health agency approximately 15

miles away. Aaction's commitment is to a population that is

difficult to serve. Local population accessibility to the

proposed home health services would be increased by approval of

both applications.

21. Medicare-certified agencies apply their own admission

criteria and decide whether to accept patients, leaving some

patients in need and without access to services in the

applicants' service area. An informal survey directed by Michael

Schwartz suggests there are existing agencies which refuse to

treat AIDS patients, that do not provide services at night and on

weekends, and that refuse to treat people in poverty areas. The

targeted Medicare-eligible population would enjoy enhanced

accessibility and availability of home health services by both

applicants, if approved.

22. The addition to the district of a Medicare-certified

home health agency (Nursing Unlimited) which utilizes a JCAHO-

approved centralized case management system would also tend to

enhance the availability, accessibility, and adequacy of services

provided in the district.

23. When non-Medicare-certified agencies receive a request

to care for Medicare patients, the request must be forwarded to a

Medicare-certified entity, which in turn will contact the

patient. The non-Medicare agency may then be authorized under

subcontract to contact and serve the patient and to bill the

Medicare-certified agency for its services. In turn, the

Medicare-certified agency will add on its overhead and forward a

higher bill to Medicare. This process also results in delays in

patient treatment. Approval of these applications would likely

result in better patient care, without delays, and at lower

costs. AHCA has determined that eliminating such subcontract

arrangements will eliminate an unnecessary level of

administrative costs. AHCA also discourages subcontract

arrangements which remove direct control of patient care from the

Medicare certified entity. See Allstar Care , supra .

24. District 11 home health visits increased by 410,000

visits in 1995 and 1996. A projection of 600,000 new visits

during 1995 through 1997 is reasonable. Nursing Unlimited and

Aaction each project approximately 25,000 visits during their

second year of operation. Approval of these applicants would not

adversely impact the utilization of existing home health

providers in the district. Both applicants here will

specifically enhance access by the needy Hispanic population.

25. AHCA offered no competent evidence to contradict the

conclusions of the applicants' experts, nor did it effectively

challenge the accuracy, validity, or reliability of the

methodologies they employed.

26. AHCA's expert and sole witness, James McLemore, is an

application review specialist who candidly admitted he has no

experience in the development of need methodologies but relies

instead on the expertise of health care planners such as Mr.

Schwartz or Mr. Richardson. Mr. McLemore's anecdotal testimony

regarding fraudulent or phantom visits, and AHCA's concern that

both state and federal agencies are investigating fraud in the

home health care business, raise compelling licensing issues but

are insufficient to defeat otherwise convincing evidence in favor

of these certificates of need.

CONCLUSIONS OF LAW

27. The Division of Administrative Hearings has

jurisdiction in this proceeding pursuant to Sections 120.569 and

120.57(1), Florida Statutes (Supp. 1996), and Section 408.039(5),

Florida Statutes.

28. An applicant for a certificate of need must demonstrate

entitlement to its award of the certificate. Boca Raton

Artificial Kidney Center vs. Department of Health and

Rehabilitative Services , 475 So. 2d 260 (Fla. 1st DCA 1985). A

balanced consideration of applicable statutory and rule criteria

must be made. Humana Inc. vs. Department of Health and

Rehabilitative Services , 469 So. 2d 889 (Fla. 1st DCA 1985);

Department of Health and Rehabilitative Services vs. Johnson Home

Health Care, Inc. , 447 So. 2d 361 (Fla. 1st DCA 1994). The

weight to be given each criterion is not fixed but varies

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

Inc. vs. Department of Health and Rehabilitative Services , 462

So. 2d 83 (Fla. 1st DCA 1985). No single criterion, except

perhaps the applicant’s financial inability, is outcome

determinative. Beverly Savannah Cay Manor Inc. vs. AHCA , 19 FALR

3583, 3598 (Final Order September 15, 1997); North Shore Medical

Center, Inc. vs. AHCA , DOAH No. 92-4992 (Recommended Order

September 9, 1993; Final Order November 8, 1993).

29. The findings of fact herein reflect the balanced

consideration required by the cases and statutes. Application of

the legal CON criteria to each of the applicants leads to the

conclusion that each proposed project, on balance, satisfies or

meets the applicable criteria so as to entitle each to a CON for

a Medicare-certified home health agency in District 11.

30. As reflected in the Prehearing Stipulation, the parties

agree that both applications meet or satisfy, the state health

plan and district health plan preferences and all of the

statutory and rule review criteria, except this one:

The availability, quality of care,

efficiency, appropriateness, accessibility,

extent of utilization, and adequacy of like

and existing home health care services in

District 11. Section 408.035(1)(b), Florida

Statutes.

Both applications meet the overwhelming majority of all review

criteria, and, on balance, should be approved.

31. AHCA has approved several home health agency applicants

in circumstances where the applicants were unable to totally

satisfy subsection §408.035(1)(b), but did satisfy most other

criteria. Home Health Care Services vs. AHCA , DOAH Case No.

96-4058 (Recommended Order June 27, 1997; Final Order

September 16, 1997); Allstar Care, Inc. vs. AHCA , DOAH Case No.

96-4064 (Recommended Order September 3, 1997; Final Order

November 6, 1997). Further, AHCA recently issued a final order

approving a preliminarily-denied home health agency applicant

even though there were no findings that existing district

services lacked availability, quality, efficiency,

appropriateness, utilization or adequacy. Shands Teaching

Hospital and Clinics, Inc. vs. AHCA , DOAH Case No. 96-4075

(Recommended Order March 10, 1997; Final Order May 12, 1997).

The foregoing cases demonstrate that the sole remaining criteria

at issue here is not pivotal.

32. In Shands , the CON application was approved by AHCA's

Final Order adopting recommended order conclusion of law

paragraph 47:

Shands failed to demonstrate that home health

services in District 4 are not available,

high quality, efficient, appropriate or

adequate. Shands did demonstrate that

approval of CON 8391 will make home health

services more available. Subsection

408.035(1)(b).

Like the Shands application, the Aaction and Nursing Unlimited

applications meet the state and local health plan preferences and

statutory criteria and both Aaction and Nursing Unlimited have

proven that their approval will enhance access.

33. AHCA’s suggestion that there is no need for new

agencies because there is sufficient capacity among existing

providers has been rejected in AHCA’s Shands final order, at

paragraph 21:

The existing supply of comparable services in

District 4 can theoretically and legally

expand to provide the projected . . . visits

in 1997. However, competition from new

providers encourages quality improvements and

maintains cost-efficient agency sizes.

Moreover, if AHCA’s argument were correct, then no new agencies

could ever be approved.

34. The applicants in this case will improve the

availability, quality of care, efficiency, appropriateness,

accessibility, extent of utilization, and adequacy of like and

existing home health care services in District 11.

35. Aaction and Nursing Unlimited each offered reasonable

numeric need methodologies with credible underlying assumptions

which demonstrate a need for at least two additional agencies.

Nursing Unlimited's numeric need formula prepared by Mike

Schwartz very conservatively projects a need for more than two

new agencies and suggests an optimum agency size of approximately

34,000 visits. Administrative Law Judge Maloney recently

determined Mr. Schwartz' identical home health need methodology

was reasonable, and stated at paragraph 197 of his recommended

order:

After taking note of the statistics for

actual patient visit growth in District 2

from 1991 to 1994, Michael Schwartz began

with a conservative number of 60,000 new

patient visits per year, a number half of the

growth for the lowest growth year of that

time period. Multiplying that number times

the three horizon years of 1994-97 equals

180,000 new patient visits from 1994 which

yields a need for 5.2 agencies.

Care First, Inc. vs. AHCA , DOAH Case No. 96-4053 (Recommended

Order June 9, 1997). That need determination for 5.2 agencies

translates to an average of 34,615 visits per agency. In another

recent case, AHCA adopted Judge Maloney’s finding that

"[p]revious studies, moreover, have shown that all economies of

scale are realized at around 30,000 visits per year." AHCA then

approved two new agencies in District III, after they were

preliminarily denied on essentially the same grounds asserted by

AHCA in the instant proceeding. Home Health Care Services ,

supra .

36. The question of whether these applications should be

comparatively reviewed is rendered moot by the applicants’

demonstration of a need in excess of two new agencies. Once

sufficient need has been established for the number of

applicants, the only remaining issue is whether each applicant

individually meets the applicable relevant criteria. In this

case the applicants have met their burden.

RECOMMENDATION

Based on the foregoing findings of fact and conclusions of

law, it is RECOMMENDED:

That the Agency for Health Care Administration enter its

final order granting CON No. 8428 to Nursing Unlimited 2000, Inc.

and CON No. 8432 to Aaction Home Health Care, Inc.

DONE AND ORDERED this 22nd day of December, 1997, in

Tallahassee, Leon County, Florida.

___________________________________

MARY CLARK

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 22nd day of December, 1997.

COPIES FURNISHED:

Michael Manthei

Broad and Cassel

1130 Broward Financial Center

500 East Broward Boulevard

Fort Lauderdale, Florida 33394

Moses E. Williams

Office of the General Counsel

Agency for Health Care Administration

Fort Knox Building 3, Suite 3400

2727 Mahan Drive

Tallahassee, Florida 32308-5403

R. David Prescott

Ruthledge Ecenia Underwood

Purnell and Hoffman, P.A.

Post Office Box 551

Tallahassee, Florida 32302-0551

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.