state agency action report - Agency for Health Care Administration
state agency action report - Agency for Health Care Administration
state agency action report - Agency for Health Care Administration
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STATE AGENCY ACTION REPORT<br />
ON APPLICATION FOR CERTIFICATE OF NEED<br />
A. PROJECT IDENTIFICATION<br />
1. Applicant/CON Action Number<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc./CON #10061<br />
18 Aquamarine Avenue<br />
Naples, Florida 34114<br />
Authorized Representative: Ms. Judith Grey<br />
(201) 919-4905<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida/CON #10062<br />
717 North Harwood, Suite 1500<br />
Dallas, Texas 75201<br />
Authorized Representative: Mr. Jason S. Howard<br />
(214) 922-9711<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc./CON #10063<br />
6400 Shafer Court, Suite 700<br />
Rosemont, Illinois 60018<br />
Authorized Representative: Ms. Marcia Norman<br />
(847) 692-1127<br />
United Hospice of Florida, Inc./CON #10064<br />
1626 Jeurgens Court<br />
Norcross, Georgia 30093<br />
Authorized Representative: Mr. Neil L. Pruitt, Jr.<br />
(770) 925-4788
CON Action Numbers: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida/CON #10065<br />
505 East Huntland Drive, Suite 270<br />
Austin, Texas 78752<br />
Authorized Representative: Ronald T. Luke, JD, PhD<br />
(512) 371-8166<br />
2. Service Area/Subdistrict<br />
Hospice Service Area 4A (Baker, Clay, Duval, Nassau, and<br />
St. Johns Counties)<br />
B. PUBLIC HEARING<br />
A public hearing was not held or requested regarding the proposals to<br />
establish a new hospice program in Hospice Service Area 4A. Letters of<br />
support are detailed below:<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) included<br />
two letters of support in its application and the <strong>Agency</strong> independently<br />
received one letter. All three letters were signed and dated during<br />
December 2009. Sandra L. Murman, <strong>for</strong>mer member of the Florida<br />
House of Representatives (1996-2004) <strong>state</strong>d she served as chair of the<br />
<strong>Health</strong> and Human Services Appropriations Committee and the <strong>Health</strong><br />
<strong>Care</strong> Council. Representative Murman <strong>state</strong>d she has come to know<br />
Compassionate <strong>Care</strong> over the last year and that the organization has her<br />
highest respect. She also <strong>state</strong>d that she believes the applicant would<br />
bring a commitment to excellence and professionalism to the people of<br />
Duval and surrounding counties. James Wood, President and CEO,<br />
Memorial Hospital-Jacksonville and Thomas Pentz, Chief Executive<br />
Officer, Orange Park Medical Center (located in Clay County, Florida)<br />
submitted letters indicating that they would be willing to enter into<br />
appropriate agreements <strong>for</strong> the applicant to use their facility‟s hospital<br />
beds to provide inpatient level hospice care.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) submitted 46<br />
unduplicated letters of support. These letters were arranged in the<br />
following order: the Dream Foundation (one letter) acute care hospital,<br />
skilled nursing facility (SNF), assisted living facility (ALF) and related<br />
support (11 letters) and family letters of thanks (34 letters).<br />
2
CON Action Number: 10061-10065<br />
Thomas Rollerson, Founder/President of the Dream Foundation, <strong>state</strong>d<br />
that his foundation is the first national wish-granting organization <strong>for</strong><br />
adults 18 years of age or older with life-limiting illnesses, and that it was<br />
founded in Santa Barbara, Cali<strong>for</strong>nia in 1994. According to Mr.<br />
Rollerson, the Dream Foundation is made possible in part by a grant<br />
from the Odyssey Vista<strong>Care</strong> Hospice Foundation and has had the<br />
pleasure of working with Odyssey‟s Florida programs by granting wishes<br />
to Florida patients. Mr. Rollerson <strong>state</strong>d that he has been impressed<br />
with Odyssey‟s dedication and that the company is a national provider of<br />
quality hospice services.<br />
The 11 support letters from a Hospice Service Area 4A acute care<br />
hospital, SNFs, ALFs and related facilities/providers were dated during<br />
November through December 2009. These were from James Wood,<br />
President and CEO, Memorial Hospital-Jacksonville; Kevin Harris, MSH,<br />
NHS, RHP, Executive Director, Administrator, W. Frank Wells Nursing<br />
Home (located in Baker County, Florida); Jacqueline Smith, RN, BSN,<br />
Director of Nursing, Jacksonville Nursing and Rehab Center; Neil<br />
Ramski, NHA, Administrator, Cedar Hills <strong>Health</strong>care Center; Paul Callis,<br />
Director of Social Services, Moultrie Creek Nursing and Rehabilitation<br />
Center (St. Johns County, Florida); John Schaum, Executive Director,<br />
Sunrise Assisted Living of Jacksonville and Barbara Tidwell, RD, LD,<br />
MHA, FACHE, Owner/Administrator, Some Place Like Home, Inc. A<br />
recurring theme is that increased competition and choice will enhance<br />
existing hospice services. The hospital and SNF support letters make no<br />
mention of entering into appropriate agreements <strong>for</strong> the applicant to use<br />
hospital or SNF beds to provide inpatient-level hospice care. Ms. Tidwell<br />
of Some Place Like Home, Inc. (an ALF) specifically expresses concern<br />
with the existing hospice landscape in Hospice Service Area 4A regarding<br />
a need <strong>for</strong> more communication with family during the dying process.<br />
The 34 support letters of thanks from family members served by the<br />
applicant were mostly hand written notes and cards of appreciation <strong>for</strong><br />
the care provided a loved one. Five of these were from Daytona Beach,<br />
six had a Miami-Dade County, Florida address but most did not<br />
distinguish a location.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) submitted 105<br />
unduplicated letters of support and the <strong>Agency</strong> received one support<br />
letter independently. These were categorized by the applicant as 17<br />
professional and 89 family and friend support letters.<br />
The applicant‟s 17 professional support letters were from Florida and<br />
non-Florida hospitals, a Florida university professor, a Hospice Service<br />
Area 4A local bank, non-Florida medical doctors, non-Florida nursing<br />
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CON Action Numbers: 10061-10065<br />
homes, and Seasons Hospice staff. All of these letters were signed and<br />
most were dated December 2009. A sampling of these follows: Hoyt<br />
Ross, Chief Executive Officer, Kindred Hospital - North Florida (Clay<br />
County, Florida); staff from Henry Ford Hospital (located in Detroit,<br />
Michigan); Martin Gorbien, MD, Rush University Medical Center (located<br />
in Chicago, Illinois); Christopher Holroyde, MD, Phoenixville Hospital<br />
(located in Phoenixville, Pennsylvania); Caprice Knapp, PhD, Assistant<br />
Professor, University of Florida College of Medicine and Liz Porter,<br />
Business Development Specialist, Heritage Bank of North Florida (located<br />
in Clay County, Florida). Mr. Ross, of Kindred Hospital - North Florida,<br />
<strong>state</strong>d he would welcome the applicant into his facility and is willing to<br />
contract <strong>for</strong> general inpatient levels of care. Mr. Ross‟ letter is not dated.<br />
Caprice Knapp, PhD, of the University of Florida‟s College of Medicine<br />
<strong>state</strong>d she is impressed by the applicant‟s devotion to providing pediatric<br />
palliative care and the Kangaroo Kids program in Chicago. Dr. Gorbien<br />
of Rush University Medical Center commented on the applicant‟s “open<br />
access” program. Dr. Gorbien <strong>state</strong>d this program allows individuals in<br />
hospice to continue to receive certain treatments or procedures that<br />
might be considered too aggressive (i.e., highly costly), by other hospices.<br />
Matthew Shuster, MD, Co-Medical Director, Seasons Hospice and<br />
Palliative <strong>Care</strong> of Massachusetts described “open access” as a policy in<br />
which no patient is rejected simply because they choose to continue<br />
some element of life-sustaining therapy. The <strong>Agency</strong> recognizes that as<br />
part of Season‟s admissions policy, the patient/legal representative must<br />
make an in<strong>for</strong>med decision to <strong>for</strong>ego curative treatment <strong>for</strong> the terminal<br />
illness in preference <strong>for</strong> palliative treatment/services. A recurring theme<br />
is that increased competition and choice will enhance existing hospice<br />
services.<br />
The 89 unduplicated support letters of thanks from family members<br />
served by the applicant were mostly hand written notes and cards of<br />
appreciation <strong>for</strong> the care provided a loved one. None were from Florida<br />
residents, as the applicant does not operate in Florida. Many of the<br />
letters were not dated and did not distinguish a location. Most expressed<br />
exceptional thanks and gratitude <strong>for</strong> hospice services provided to family,<br />
friends or loved ones. The <strong>Agency</strong> notes the many comments in these<br />
support letters and cards about the applicant providing services beyond<br />
those commonly or frequently offered by hospice providers (such as<br />
ventilator care). Many of these cited the applicant‟s promptness, genuine<br />
caring and attentiveness to patient and family needs.<br />
4
CON Action Number: 10061-10065<br />
United Hospice of Florida, Inc. (CON #10064) submitted 63<br />
unduplicated letters of support and the <strong>Agency</strong> received two support<br />
letters <strong>for</strong> this applicant independently. The applicant categorized these<br />
letters as follows: community and United Hospice staff (20 letters); UHS-<br />
Pruitt subsidiaries (five letters) and United Hospice patients and families<br />
(39 letters).<br />
The 21 unduplicated support letters from the community and United<br />
Hospice staff were all signed or at least had distinguishing applicable<br />
provider letterhead. Most were signed between November 12 and<br />
December 14, 2009. A sample of these support letters include: James<br />
Wood, President and CEO, Memorial Hospital-Jacksonville; Hoyt Ross,<br />
CEO and Administrator, Kindred Hospital-North Florida (located in Clay<br />
County, Florida); Kevin Harris, MSH, NHA, CASP, Administrator, W.<br />
Frank Wells Nursing Home; Tamara Patton, Coordinator, Emergency<br />
Services and Homeless Coalition of Jacksonville, Inc.; Brian Snow,<br />
Director of Family Services, I.M. Sulzbacher Center <strong>for</strong> the Homeless;<br />
Ju‟Coby Pittman-Peele, CEO/President, Carla White Mission, Inc.; Mark<br />
Landschoot, Executive Director, Family Promise of Jacksonville; Julie<br />
Wood, BSRN, Nurse <strong>Care</strong> Coordinator, The Medical Home <strong>for</strong> Homeless<br />
Children Project; Van Snead, Home Safe Program Manager, Presbyterian<br />
Social Ministries, Inc.; Mary Canestorp, Administrator, Buckingham<br />
Smith Assisted Living Facility (located in St. Johns County, Florida); Paul<br />
Callis, MS, Social Services Director, Moultrie Creek Nursing and<br />
Rehabilitation Center and Andrew McCraw, MD, McCraw Family<br />
Medicine (located in Simpsonville, South Carolina). Many of these<br />
support letters had an emphasis on care <strong>for</strong> the homeless (both adults<br />
and children). Ms. Canestrop <strong>state</strong>d that she has met with United<br />
Hospice representatives and believes they share “our quality and<br />
compassion to provide our residents with the highest level of care”. She<br />
also <strong>state</strong>d that her facility is affiliated with the St. Johns Welfare<br />
Federation. Bill Saunders, RN, BSN, MBA, Administrator, Confident<br />
<strong>Care</strong> of Florida Corp (located in Jacksonville, Florida) and Carol Waters,<br />
life coach, licensed massage therapist, hypnotist, and Clay County<br />
resident, expressed dissatisf<strong>action</strong> with the current hospice environment<br />
in Hospice Service Area 4A, with Mr. Saunders commenting on decreased<br />
care of hospice patients in some instances, particularly with regard to<br />
nursing care. Ms. Waters <strong>state</strong>d that existing hospices in the area are<br />
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CON Action Numbers: 10061-10065<br />
less receptive to massage, aroma and music therapy than the applicant.<br />
Gayle Eckerd, Chief Executive Officer, River Point Behavioral <strong>Health</strong> and<br />
Wekiva Springs Center <strong>for</strong> Women (both located in Duval County,<br />
Florida); John Griggers, Administrator, Life <strong>Care</strong> Center of Orange Park,<br />
(Clay County, Florida) and Stephen Jordan, Administrator, Quality<br />
<strong>Health</strong> of Fernandina Beach (Nassau County, Florida) indicated their<br />
willingness to contract or enter into appropriate arrangements with the<br />
applicant <strong>for</strong> general inpatient levels of care.<br />
The five letters from UHS-Pruitt subsidiaries were signed with a<br />
December 9, 2009 signature date. All signatories indicate a location of<br />
Norcross, Georgia. Richard Gerhardt, Vice President of <strong>Health</strong> Services<br />
issued two of the five letters. Mr. Gerhardt indicated that his company<br />
would provide appropriate medical equipment and supplies. Other<br />
subsidiary letters indicated interest in providing pharmacy, nutritional,<br />
dietary counseling, physical, occupational, speech and respiratory<br />
therapy and related services.<br />
The 39 unduplicated support letters of thanks from family members<br />
served by the applicant were mostly hand written notes and cards of<br />
appreciation <strong>for</strong> the care provided to a loved one/family member. Many<br />
of these thank United Hospice and some Peachtree Christian Hospice (a<br />
Georgia Hospice managed by UHS). Many of the letters and cards were<br />
not dated. Of those dated, the year was 2008 or 2009.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) submitted 53<br />
unduplicated letters of support and the <strong>Agency</strong> independently received<br />
two letters of support. Nearly all were signed and all have applicable<br />
affiliate letterhead; most are dated December 2009. The letters are<br />
described below in the following order: those received by the <strong>Agency</strong><br />
independently, three found in CON Application #10065, Tab 11-<br />
Charitable Contribution Condition Letters and 50 letters in Tab 15-Letter<br />
of Support. The applicant‟s Tab 15 included a list of these „noncharitable<br />
contribution‟ condition letters. Four support letters lack a<br />
signature: John Drew, Tax Collector, Nassau County, Florida; Sharon<br />
James, President, Daytona Beach Black Nurses Association; Leonard<br />
Love, Archbishop, Truth <strong>for</strong> Living Ministries (Duval County, Florida) and<br />
Nancy Austin, RN, CHPN, Chapter President, Hospice and Palliative<br />
Nurses Association (Miami-Dade County, Florida). Thirty-seven of the 55<br />
support letters have a Hospice Service Area 4A address. The support<br />
letters are identified by the following groups: charitable contribution<br />
6
CON Action Number: 10061-10065<br />
letters, elected officials, willingness to contract letters, Hospice Service<br />
Area 4A support, and non-Hospice Service Area 4A support. A relatively<br />
common theme is the applicant‟s seeking to provide hospice services to<br />
the African American population, the HIV/AIDS population and patients<br />
with other non-cancer diagnosis that are in need of hospice service.<br />
Michele Querry, Director of Major Gifts, Florida State College Foundation<br />
provided a $298,690 proposal <strong>state</strong>d to outline unique partnership<br />
opportunities <strong>for</strong> VITAS to assist in the Foundation‟s „critical funding<br />
needs‟, $285,000 of which will be submitted <strong>for</strong> State matching funds<br />
and $13,690 matched by the Foundation <strong>for</strong> Florida‟s Community<br />
Colleges <strong>for</strong> the Blue Cross Blue Shield of Florida Nursing and Allied<br />
<strong>Health</strong> Scholarship. The State matching funds consist of $190,000 <strong>for</strong><br />
the Northeast Florida Initiative <strong>for</strong> Nursing Work<strong>for</strong>ce Diversity, $55,000<br />
<strong>for</strong> a VITAS Innovative Hospice <strong>Care</strong> Endowed Teaching Chair and<br />
$40,000 <strong>for</strong> a VITAS Innovative Hospice <strong>Care</strong> Endowed Scholarship.<br />
Barbara Drake, Chair, Board of Directors and Connie Hodges, President,<br />
United Way of Northeast Florida, <strong>state</strong>d that the United Way would be<br />
willing to steward a VITAS gift of up to $500,000 that would span over a<br />
two to three year period beginning in the summer of 2010. According to<br />
this letter, the funds would be used to expand the Elder <strong>Care</strong> Advocacy<br />
Program provided to Shands Jacksonville Medical Center. Richard<br />
Dan<strong>for</strong>d, President, Jacksonville Urban League (JUL) indicated that a<br />
proposed $50,000 VITAS grant would be used to support anti-obesity<br />
programs promoted by the JUL, educational end-of-life JUL quarterly<br />
seminars and workshops and expansion of JUL community health and<br />
end-of-life care awareness initiatives.<br />
Eight elected officials support the applicant‟s proposal. These officials<br />
include: the Honorable Audrey Gibson, District 15, Florida House of<br />
Representatives; the Honorable Stacey Johnson, County Commissioner,<br />
Nassau County Board of County Commissioners; the Honorable John<br />
Drew, Tax Collector, Nassau County; the Honorable Tommy Hazouri,<br />
Representative, Duval County School Board and the Honorable Richard<br />
Clark (Council President), William Bishop, AIA, Michael Corrigan, Jr. and<br />
Warren Jones, Councilmen, Office of the City Council, City of<br />
Jacksonville. These letters indicated that VITAS is a leader in end-of-life<br />
care and would make an excellent additional choice of hospice providers<br />
in the area.<br />
Representatives of six Hospice Service Area 4A skilled nursing facilities<br />
expressed commitment or interest in entering into appropriate<br />
agreements to provide inpatient hospice beds, should this applicant be<br />
approved. These providers are: Chris Adams, Executive Director; Harts<br />
Harbor <strong>Health</strong> <strong>Care</strong> Center; Elizabeth Sholar, NHA, Fleet Landing;<br />
7
CON Action Numbers: 10061-10065<br />
Raymond Prudencio, NHA, CNA, Administrator and Preceptor, The<br />
Terrace at Fleming Island (Clay County, Florida); Glen<strong>for</strong>d Wright,<br />
MSHRM, BSBA, Administrator, West Jacksonville <strong>Health</strong> and<br />
Rehabilitation Center; Jerry Tomack, MHSA, NHA, Executive Director,<br />
San Jose <strong>Health</strong> and Rehabilitation Center and Eric Weisz, Executive<br />
Director, Governor‟s Creek <strong>Health</strong> and Rehabilitation Center (Clay<br />
County, Florida).<br />
Letters from Hospice Service Area 4A were received from Neal Henning,<br />
PhD, Dean of Work<strong>for</strong>ce Development, Florida State College of<br />
Jacksonville, Dr. Steven Wallace, President, Dr. Barbara Darby, North<br />
Campus/Nassau Center President and Gwendolyn Yates, Vice Chair,<br />
Duval County, District Board of Trustees, Florida State College at<br />
Jacksonville. Kevin Harris, MSH, Administrator, W. Frank Wells Nursing<br />
Home <strong>state</strong>d confidence that residents of his county will significantly<br />
benefit from this project, if approved. Archbishop Leonard Love, Truth<br />
<strong>for</strong> Living Ministries, <strong>state</strong>d interest in the applicant‟s cultural sensitivity<br />
to the African American community. Deborah Thompson, Owner,<br />
Deborah Thompson Consultants identified herself as a Board Member of<br />
the Jacksonville Urban League and Agape Community <strong>Health</strong> Center, a<br />
federally qualified health center [FQHC], and <strong>state</strong>d that VITAS is a<br />
proven leader with a record of accomplishments and that she is confident<br />
that VITAS will implement out-reach programs <strong>for</strong> the African-American<br />
community.<br />
Many of the applicant‟s letters of support from outside Hospice Service<br />
Area 4A attest to VITAS‟ success in other parts of Florida and the nation.<br />
These include Jerry Santeiro, Executive Director, Guardian Program of<br />
Dade County, Inc., Public Guardian <strong>for</strong> the 11th Judicial Circuit (Miami-<br />
Dade County, Florida), Linda Quick, President, South Florida Hospital &<br />
<strong>Health</strong>care Association cited the success VITAS has experienced in the<br />
South Florida area particularly with African American and terminally ill<br />
non-cancer patients. Max Rothman, JD, LLM, President and CEO,<br />
Alliance <strong>for</strong> Aging, Inc. (Miami-Dade and Monroe Counties, Florida) also<br />
cited the applicant‟s excellent service to the African American terminally<br />
ill and indicated that like results might be realized in Hospice Service<br />
Area 4A with approval of this applicant. Maria Lazo, Miami-Dade County<br />
Hispanic Affairs Advisory Board Director, indicated that VITAS has<br />
community outreach programs which recognize that hospice outreach is<br />
necessary <strong>for</strong> persons of Hispanic descent and African American descent,<br />
and that those with non terminal illnesses are better served. She <strong>state</strong>d<br />
that she is confident VITAS will address these needs in District 4A.<br />
Sharon Jones, President, Daytona Beach Black Nurses Association,<br />
<strong>state</strong>d that VITAS has provided scholarships <strong>for</strong> student nurses at<br />
Daytona State College and at Bethune Cookman University <strong>for</strong> the past<br />
8
CON Action Number: 10061-10065<br />
four years, has been especially sensitive to African American end-of-life<br />
issues and is uniquely qualified to provide culturally appropriate<br />
in<strong>for</strong>mation, services and care to African Americans and traditionally<br />
underserved populations. Maria Pams, MHS, Project Director, Senior<br />
Community Services Program, American Association of Retired Persons<br />
(Miami-Dade County, Florida) recognized the applicant‟s success in<br />
reaching out to the African American population in her area. Martha<br />
Sanchez, Chief Executive Officer, Area <strong>Health</strong> Education Center (Miami-<br />
Dade County) makes similar comments. Nancy Auster, RN, CHPN,<br />
Chapter President, Hospice and Palliative Nurses Association (Miami-<br />
Dade County, Florida) <strong>state</strong>d that the applicant will provide a<br />
tremendous service to the underserved of the area, particularly the<br />
African American community. Deborah Alexander, President, the<br />
Amyotrophic Lateral Sclerosis (ALS) Association of Florida Chapter<br />
(Hillsborough County, Florida), indicated that VITAS has consistently<br />
demonstrated commitment to ALS patients. Marco Carrasco, NHA,<br />
MHSA, Administrator, West Gables <strong>Health</strong> <strong>Care</strong> Center and Region 1<br />
Vice President, Florida <strong>Health</strong> <strong>Care</strong> Association, indicated that VITAS‟s<br />
programs bring value to his community and would bring similar value to<br />
the proposed area. Barbara Grasch, LMFT, Director of Program Services,<br />
Alzheimer‟s Association Southeast Florida Chapter (Palm Beach County,<br />
Florida), and Patricia Lange, Executive Director, Florida Assisted Living<br />
Association (located in Tallahassee, Florida) also submitted letters of<br />
support.<br />
Support letters from national African American organizations were also<br />
included in the application. Iva Carruthers, PhD, General Secretary,<br />
Samuel DeWitt Proctor Conference, Inc. (located in Chicago, Illinois),<br />
indicated that VITAS has had success with hospice care from an African<br />
American faith perspective. Bishop Arthur House, Jr., Full Gospel<br />
Baptist Church Fellowship International, Office of Home Missions<br />
(located in Hampton, Virginia) also indicated that VITAS has had<br />
successful ef<strong>for</strong>ts to reach out to the African American community<br />
concerning end-of-life concerns. Millicent Gorham, Executive Director,<br />
National Black Nurses Association, Inc. <strong>state</strong>d that <strong>for</strong> the past five years<br />
VITAS has provided continuing education programs at her organization‟s<br />
national conferences including one in Broward County, Florida in 2006.<br />
Ms. Gorham also indicated that recently, principals from VITAS engaged<br />
the Daytona Beach Black Nurses Association to discuss issues around<br />
end-of-life care.<br />
9
Summary of Contractual Letters of Support<br />
CON Action Numbers: 10061-10065<br />
CON Application #10061 (Compassionate <strong>Care</strong>) included two acute<br />
care hospital letters of willingness to provide inpatient beds <strong>for</strong> hospice<br />
services – one from Memorial Hospital-Jacksonville (Duval County) and<br />
one from Orange Park Medical Center (Clay County).<br />
CON Application #10062 (Odyssey) does not include an acute care<br />
hospital or SNF commitment letter to enter into inpatient bed<br />
arrangements.<br />
CON Application #10063 (Seasons) included a letter of willingness from<br />
Kindred Hospital-North Florida to provide inpatient beds <strong>for</strong> hospice<br />
services.<br />
CON Application #10064 (United) included four letters of willingness to<br />
provide inpatient beds <strong>for</strong> hospice services. These were from River Point<br />
Behavioral <strong>Health</strong> which also operates Wekiva Springs Center <strong>for</strong> Women<br />
(Duval County inpatient psychiatric hospitals) and two SNFs – Quality<br />
<strong>Health</strong> of Fernandina Beach (Nassau County) and Life <strong>Care</strong> Center of<br />
Orange Park (Clay County).<br />
CON Application #10064 (VITAS) included six letters of willingness<br />
from SNF providers to provide inpatient beds <strong>for</strong> hospice services. Two of<br />
these are located in Clay County, The Terrace at Fleming Island and<br />
Governor‟s Creek <strong>Health</strong> and Rehabilitation Center and four are Duval<br />
County nursing homes: Fleet Landing, Harts Harbor <strong>Health</strong> <strong>Care</strong> Center,<br />
San Jose <strong>Health</strong> and Rehabilitation Center and West Jacksonville <strong>Health</strong><br />
and Rehabilitation Center.<br />
C. PROJECT SUMMARY<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061), a <strong>for</strong>profit<br />
provider, proposes the establishment of a new hospice program in<br />
Hospice Service Area 4A, consisting of Baker, Clay, Duval, Nassau and<br />
St. Johns Counties. Compassionate <strong>Care</strong> was founded in 1993 and has<br />
developed 23 start-up hospice programs in 15 <strong>state</strong>s: Delaware, Georgia,<br />
Illinois, Kansas, Massachusetts, Michigan, Minnesota, Missouri,<br />
Nebraska, New Jersey, New York, Pennsylvania, South Dakota, Texas<br />
and Wisconsin. Compassionate <strong>Care</strong> also has CON approval via CON<br />
#10036 to establish a program in Hospice Service Area 6B and <strong>state</strong>s<br />
this program is projected to be operational in February 2010. According<br />
10
CON Action Number: 10061-10065<br />
to the applicant, Compassionate <strong>Care</strong> is an expert in start-up operations,<br />
in programs that are opened in markets with existing providers and that<br />
none of its programs were “purchased” from other providers.<br />
Compassionate <strong>Care</strong> <strong>state</strong>s that it will aggressively address the unmet<br />
hospice need in Hospice Service Area 4A, and will seek to identify and<br />
serve any underserved groups (racial, religious, financial, diagnostic<br />
category).<br />
Compassionate <strong>Care</strong> <strong>state</strong>s that it will establish three office locations<br />
upon commencement of services including one in Duval County (zip code<br />
32218), one in Clay County in the Orange Park area (zip code 32073) and<br />
one in St. Johns County (zip code 32092). The applicant <strong>state</strong>s these<br />
three locations, in total, will serve the entirety of the hospice service area.<br />
The applicant is proposing total project costs of $227,616 <strong>for</strong> equipment,<br />
project development and start-up costs.<br />
In its Schedule C, the applicant includes the following general <strong>state</strong>ment<br />
of conditions and proposes eight specific conditions:<br />
Compassionate <strong>Care</strong> Hospice’s General Statement on Willingness to<br />
Accept Conditions in Service Area 4A<br />
It has become a routine practice <strong>for</strong> many hospice organizations to<br />
provide the various required components of hospice services through<br />
lengthy listing of numerous specific conditions <strong>for</strong> award of the CON. As<br />
required by law, Compassionate <strong>Care</strong> Hospice is willing to accept any<br />
such conditions on its CON based on any representations made<br />
throughout this CON application.<br />
Compassionate <strong>Care</strong> will provide all of the required components of<br />
hospice care, and meet all Medicare conditions of participation, and<br />
Florida hospice licensure requirements, including the provision of all<br />
levels of services (routine home care, continuous care, general inpatient,<br />
respite) to all type of patients (cancer, non-cancer, Alzheimer's, COPD,<br />
elderly, young adult, pediatric) without regard to race, ethnicity, gender,<br />
age, religious affiliation, diagnosis, financial status, insurance status, or<br />
any other discriminating factor.<br />
Compassionate <strong>Care</strong> commits to offering excellent quality specialized and<br />
individualized programs delivered by highly qualified interdisciplinary<br />
teams of professionals, and will implement continuous quality<br />
improvement, per<strong>for</strong>mance improvement, quality assurance and<br />
monitoring programs. Compassionate <strong>Care</strong> will offer all types of services<br />
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CON Action Numbers: 10061-10065<br />
including physical care and pain management, bereavement counseling<br />
and support services (<strong>for</strong> as long as the bereaved needs such services,<br />
without limitation on duration), psycho-social services, spiritual care and<br />
counseling, memorial programs and services, palliative radiation or<br />
chemotherapy, and massage, music, pet, aroma, and other alternative<br />
therapy programs. Compassionate <strong>Care</strong> will implement a volunteer<br />
program and offer a wide array of services through its volunteers.<br />
Compassionate <strong>Care</strong> is firmly committed to the continuing and ongoing<br />
training, orientation, and education of its staff, and will implement<br />
specific programs such as tuition reimbursement, ongoing in-service and<br />
training programs, library resources and payment <strong>for</strong> certification of<br />
staff. Compassionate <strong>Care</strong> will ensure that its staff has the resources,<br />
equipment (such as laptop computers, Personal Digital Assistants, or<br />
other IT equipment) to per<strong>for</strong>m effectively in the delivery of care to their<br />
patients and families.<br />
Compassionate <strong>Care</strong> will conduct extensive community education and<br />
outreach programs in all communities, including all racial, ethnic, or<br />
religious minority communities, Veterans groups and organizations, and<br />
will initiate specialized programs and services to meet the individual<br />
needs of such communities in terms of language needs or specialized<br />
cultural or religious needs. Examples include such programs as<br />
Compassionate <strong>Care</strong>'s Jewish Hospice Certification, use of a culturally<br />
diverse staff, use of bilingual staff, and production of education materials<br />
and service <strong>for</strong>ms in Spanish, Vietnamese, Russian or other languages as<br />
needed in the community; and sensitivity and training <strong>for</strong> the special<br />
needs of veterans.<br />
Compassionate <strong>Care</strong> will contribute to community organizations<br />
including universities, community colleges or other organizations<br />
involved in the training of health care professionals, or in the delivery of<br />
social services to the community.<br />
Compassionate <strong>Care</strong> will provide services beyond those mandated and<br />
reimbursed by Medicare and Medicaid, including specific financial<br />
assistance to meet the special individualized needs of patients through<br />
its charitable foundation, including special "last wishes" of a patient or<br />
family, need <strong>for</strong> specialized equipment not reimbursable, travel <strong>for</strong> a<br />
special family member to visit with a dying patient, or simply need <strong>for</strong><br />
assistance with mortgage payment, rent, utilities, groceries, or other<br />
necessities.<br />
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CON Action Number: 10061-10065<br />
Compassionate <strong>Care</strong> believes that all of the above types of programs,<br />
services, policies, and protocols should be provided by any hospice<br />
provider, and there<strong>for</strong>e would accept as a condition to its CON approval<br />
any or all of these general conditions.<br />
However, in order to assist the <strong>Agency</strong> in distinguishing Compassionate<br />
<strong>Care</strong> from other applicants, the applicant offers the following specific<br />
conditions, that are aimed at specific measurable <strong>action</strong>s that will<br />
increase access and quality of care <strong>for</strong> hospice patients.<br />
Specific Conditions<br />
1. Office Locations: In order to increase awareness and visibility of<br />
hospice services in the 3,221 square miles that represent<br />
Subdistrict 4A 1 (Baker, Clay, Duval, Nassau, and St. John's<br />
Counties) and to provide <strong>for</strong> accessible meeting places <strong>for</strong><br />
interdisciplinary care teams, bereavement support groups, family<br />
counseling meetings and sessions, community education meetings,<br />
and other types of local activities, Compassionate <strong>Care</strong> commits to<br />
opening three office locations upon commencement of services<br />
including one in Duval County (zip code 32218), targeted to<br />
meeting needs in Duval and Nassau Counties; one in Clay County<br />
in the Orange Park area (zip code 32073), targeted to meeting<br />
needs of Clay County, Baker County, and southwest Duval<br />
County; and one in St. John's County in zip code 32092 targeted<br />
to meeting the needs of St. Johns County and specifically west St.<br />
Johns. Compliance with this condition will be measured by<br />
providing to the <strong>Agency</strong> the location addresses <strong>for</strong> each office upon<br />
commencement of services.<br />
2. Program Accreditation: As a demonstration of commitment to<br />
quality, Compassionate <strong>Care</strong> will become accredited by the<br />
Community <strong>Health</strong> Accreditation Program within 24 months of its<br />
initial licensure. Compliance will be demonstrated by <strong>for</strong>warding a<br />
copy of the accreditation to the <strong>Agency</strong>.<br />
1 CON Application #10061, page #4.<br />
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CON Action Numbers: 10061-10065<br />
3. Medical Directors: Medical directors will assess every patient upon<br />
admission to hospice, and will provide patient visits in the home or<br />
place of residence. Medical directors will either be board-certified<br />
in hospice and palliative care medicine, or will apply <strong>for</strong> boardcertification<br />
within five years of employment as medical director.<br />
Compliance will be demonstrated through an annual <strong>report</strong> to the<br />
<strong>Agency</strong>.<br />
4. Community/Education Outreach Coordinator: In order to<br />
continuously assess the needs of the community, to expand the<br />
in<strong>for</strong>mation base in regard to the benefits of hospice care, and to<br />
reach populations in need that may not be easily accessible<br />
through the health care referral system, Compassionate <strong>Care</strong> will<br />
provide a full-time dedicated staff member, located in the<br />
Jacksonville office and serving all five counties, with the exclusive<br />
responsibility of serving as a community outreach coordinator to<br />
the non-health care community. This individual will work closely<br />
with the community leaders and organizations in the subdistrict<br />
focused on seeking to identify unmet hospice need in underserved<br />
populations, providing hospice in<strong>for</strong>mation and educational<br />
sessions to inner city and other area churches, civic organizations,<br />
employers, and advocacy groups such as AAA, area offices on<br />
aging, cancer support groups. Compliance will be demonstrated in<br />
an annual <strong>report</strong> to the <strong>Agency</strong> which identifies the key activities of<br />
this position on no less than a monthly basis.<br />
5. Pain Reduction: Compassionate <strong>Care</strong> will effectively reduce severe<br />
pain in its hospice patients within 48 hours of admission to<br />
hospice. Compliance may be demonstrated based upon an annual<br />
<strong>report</strong> of Compassionate <strong>Care</strong>‟s initial pain scores <strong>for</strong> patients, and<br />
recorded pain scores after 48 hours. Compassionate <strong>Care</strong> will<br />
achieve a reduction <strong>for</strong> at least 75 percent of patients with severe<br />
pain (score of seven to 10) to a pain score of five or less within 48<br />
hours of admission. This exceeds the requirement in Section<br />
400.60501, Florida Statutes.<br />
6. Other Staff Qualifications: To ensure high quality, Compassionate<br />
<strong>Care</strong> will adopt the following standards and qualifications <strong>for</strong> staff:<br />
registered nurses will be encouraged to become certified in hospice<br />
and palliative care nursing, and by the third year of operation, 50<br />
percent of all supervisory nurses shall attain such certification,<br />
with 100 percent of all supervisory nurses attaining such<br />
certification by the fifth year of operation; chaplains shall be<br />
masters of divinity, with demonstrated completion of an accredited<br />
clinical pastoral education program; social workers shall be<br />
14
CON Action Number: 10061-10065<br />
masters level and licensed clinical social workers. Compliance<br />
with these qualifications shall be demonstrated in an annual<br />
<strong>report</strong> to the <strong>Agency</strong>.<br />
7. Continuous <strong>Care</strong>: Compassionate <strong>Care</strong> commits that it will<br />
provide at least 1.5 percent of total patient days as continuous<br />
care days. They plan to have continuous care staff at the bedside<br />
within two hours of receipt of a request <strong>for</strong> such services and will<br />
maintain the service until no longer needed. Compliance will be<br />
measured and demonstrated by maintaining records of requests<br />
<strong>for</strong> continuous care and providing an annual <strong>report</strong> to the <strong>Agency</strong><br />
on response times and total patient days. See Appendix R <strong>for</strong><br />
additional in<strong>for</strong>mation on continuous care at Compassionate <strong>Care</strong>.<br />
8. Patient Visits: Compassionate <strong>Care</strong> will commit that every patient<br />
shall be contacted on a daily basis to determine their needs <strong>for</strong> the<br />
day, and all patients shall receive in-person visits from<br />
Compassionate <strong>Care</strong> staff at least five times per week <strong>for</strong> at least<br />
two hours per day. Compliance will be monitored by submitting an<br />
annual <strong>report</strong> to the <strong>Agency</strong>.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062), a <strong>for</strong>-profit provider,<br />
proposes the establishment of a new hospice program in Hospice Service<br />
Area 4A, consisting of Baker, Clay, Duval, Nassau and St. Johns<br />
Counties. The applicant <strong>state</strong>s its sole shareholder and parent is<br />
Odyssey <strong>Health</strong><strong>Care</strong> Operating B, LP, founded in 1995. The parent is<br />
<strong>state</strong>d to have approximately 92 Medicare-certified hospice programs in<br />
29 <strong>state</strong>s. The applicant also indicates that rather than attempting to be<br />
“all things to all people” it chooses to focus solely on hospice care and on<br />
its core competencies, particularly clinical competencies and its<br />
<strong>Care</strong>Beyond program, in which disease-specific hospice care is applied to<br />
applicable patients. The applicant also <strong>state</strong>s affiliation with two existing<br />
Florida hospices owned and operated by the parent – Odyssey<br />
<strong>Health</strong>care/Daytona (Hospice Service Area 4B) and Odyssey<br />
<strong>Health</strong>care/Miami (Hospice Service Area 11) 2 . Odyssey <strong>Health</strong><strong>Care</strong>‟s two<br />
Florida hospices were initially licensed during 2005 and 2006,<br />
respectively. The applicant indicates that the parent is finalizing<br />
licensure and expects to open its third Florida hospice program, Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Marion County, Inc. (Hospice Service Area 3B) in early<br />
2010 3 . The applicant <strong>state</strong>s that “special and not normal circumstances”<br />
exist in Hospice Service Area 4A and that the specific terminally ill<br />
2 Odyssey <strong>Health</strong><strong>Care</strong> of Marion County, Inc. is licensee <strong>for</strong> Service Areas 4B & 11 effective 11-1-09.<br />
3 Odyssey <strong>Health</strong><strong>Care</strong> of Marion County, Inc. added Marion County to its license effective 1-1-2010.<br />
15
CON Action Numbers: 10061-10065<br />
population not being adequately served is as follows: cancer patients age<br />
65 years and older; non-cancer patients under the age of 65 years and<br />
non-cancer patients age 65 years and older.<br />
Odyssey conditions (condition #21 below) CON approval to the immediate<br />
development of its main office in Duval County and two satellite offices,<br />
one in Clay County by the end of year one of operation and a second<br />
satellite office in Nassau County by the end of year two of operation.<br />
The applicant is proposing total project costs of $666,972 <strong>for</strong> equipment,<br />
project development and start-up costs.<br />
In its Schedule C, the applicant proposes 25 itemized conditions, as<br />
follows:<br />
1. The applicant will provide supportive hospice services, such as but<br />
not limited to: palliative radiation therapy and palliative<br />
chemotherapy related to the patient‟s terminal diagnosis. This will<br />
be measured via a signed declaratory <strong>state</strong>ment by the applicant,<br />
which may be supported via a review of patient medical records.<br />
2. The applicant will provide continuous care. This will be measured<br />
via a signed declaratory <strong>state</strong>ment by the applicant, which may be<br />
supported via a review of patient medical records.<br />
3. The applicant will implement the “<strong>Care</strong> Beyond” program. This will<br />
be measured via a signed declaratory <strong>state</strong>ment by the applicant.<br />
4. The applicant will provide hospice services 24 hours a day, seven<br />
days a week including weekend care as indicated by the patient‟s<br />
medical condition. This will be measured via a signed declaratory<br />
<strong>state</strong>ment by the applicant, which may be supported via a review<br />
of patient medical records.<br />
5. The applicant will admit all eligible patients without regard to their<br />
ability to pay. This will be measured by the applicant‟s Medicare<br />
certification which requires this standard.<br />
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CON Action Number: 10061-10065<br />
6. The applicant commits to having every patient being assessed by a<br />
physician upon admission to the hospice. This will be measured<br />
via a signed declaratory <strong>state</strong>ment by the applicant, which may be<br />
supported via a review of patient medical records.<br />
7. The applicant will immediately implement its per<strong>for</strong>mance<br />
improvement plan including the following assessments: pain<br />
management, family satisf<strong>action</strong>, employee satisf<strong>action</strong>, and<br />
referral source satisf<strong>action</strong>. This will be measured via a signed<br />
declaratory <strong>state</strong>ment by the applicant, which may be supported<br />
via a review of patient medical records.<br />
8. The applicant will make available a range of non-covered<br />
supplementary therapies such as but not limited to: pet, music,<br />
massage, aroma and other holistic treatments. This will be<br />
measured via a signed declaratory <strong>state</strong>ment by the applicant,<br />
which may be supported via a review of patient medical records.<br />
9. The applicant will implement Odyssey‟s triage and on-call<br />
programs upon licensure. These programs provide <strong>for</strong><br />
uninterrupted 24-hour care seven days a week. Further<br />
explanation of the program is offered in the application narrative.<br />
This will be measured via a signed declaratory <strong>state</strong>ment by the<br />
applicant.<br />
10. The applicant will establish a local ethics committee within the<br />
first year of operation. This will be measured via submissions of<br />
the names and other relevant in<strong>for</strong>mation of the Ethics Committee<br />
members and the related schedule of meetings to the <strong>Agency</strong>.<br />
11. The applicant will establish a local medical advisory committee<br />
within the first year of operation. This will be measured via<br />
submissions of the names and other relevant in<strong>for</strong>mation of the<br />
medical advisory committee members and the related schedule of<br />
meetings to the <strong>Agency</strong>.<br />
12. The applicant will provide educational programs, including but not<br />
limited to, in-service training (components of Odyssey University)<br />
resources to the community, including nursing homes, assisted<br />
living facilities, Council on Aging. In-service training would be<br />
offered to registered nurses, social workers, administrators and<br />
other staff that would benefit from an increased knowledge of<br />
hospice care and services. The applicant will host at least one<br />
seminar annually during the first two years of operation <strong>for</strong> clergy<br />
17
CON Action Numbers: 10061-10065<br />
and community faith leaders (The Clergy End of Life Education<br />
Program), to enhance spiritual support <strong>for</strong> hospice patients in the<br />
district. This will be measured via a signed declaratory <strong>state</strong>ment<br />
by the applicant.<br />
13. The applicant will provide patients, family members and referral<br />
sources with in<strong>for</strong>mation of services provided by the Dream<br />
Foundation. The Dream Foundation is the first national group of<br />
its kind that exists <strong>for</strong> terminally ill applicants over the age of 18.<br />
Through its Day Dreams (a program <strong>for</strong> terminally ill adults over<br />
the age of 65), Emergency Dreams and Quality of Life Dreams, the<br />
Dream Foundation provides patients and families with a sense of<br />
completion and fulfillment. Odyssey has partnered with the Dream<br />
Foundation to improve care <strong>for</strong> our patients and to advance our<br />
mutual interests in the field of hospice. This will be measured via<br />
a signed declaratory <strong>state</strong>ment by the applicant.<br />
14. The applicant, through Odyssey <strong>Health</strong><strong>Care</strong>, Inc. or the Odyssey<br />
Vista<strong>Care</strong> Hospice Foundation, will make a $25,000 contribution<br />
to an appropriate not-<strong>for</strong>-profit entity in the community to fund<br />
education <strong>for</strong> end-of-life issues. Upon approval, Odyssey will meet<br />
with the Area Council on Aging or similar organization to identify<br />
and determine the most appropriate entity within the community<br />
related to education <strong>for</strong> end-of-life issues. This will be measured<br />
via a signed declaratory <strong>state</strong>ment by the applicant and evidence of<br />
funds provided to the not-<strong>for</strong>-profit entity.<br />
15. The applicant will commit to 0.5 FTE the first year of operation to<br />
evaluate the need, if any, <strong>for</strong> an expanded children‟s hospice<br />
program in the community including, but not limited to, the need<br />
<strong>for</strong> a children‟s program that offers an expanded hospice benefit <strong>for</strong><br />
patients up to age 21. The program would focus on longer term<br />
services <strong>for</strong> patients who may not otherwise qualify <strong>for</strong> hospice<br />
such as those with developmental conditions, cancers, chronic<br />
illnesses or brain injury that shorten lives and place special<br />
demands on families. If during the first year of operation it is<br />
determined that existing children‟s hospice services in the<br />
community are available to meet local needs, the applicant will<br />
donate $25,000 to support existing local children‟s hospice<br />
programs. If after the first year there is found to be a need <strong>for</strong><br />
additional children‟s hospice services, a child and family support<br />
program interdisciplinary team will be established to support the<br />
needs of this target population. This will be measured via a signed<br />
declaratory <strong>state</strong>ment by the applicant.<br />
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CON Action Number: 10061-10065<br />
16. The applicant will commit to 0.5 FTE the first year of operation<br />
regarding community bereavement programs in the community.<br />
The bereavement program will be broadly based to extend beyond<br />
the families of patients admitted to Odyssey <strong>Health</strong><strong>Care</strong>. These<br />
programs will be an extension of the programs currently offered in<br />
the hospice service area. The applicant will provide bilingual staff<br />
to provide bereavement services to the Hispanic population,<br />
including Hispanic children. At a minimum, one bereavement<br />
group consisting of approximately eight sessions will be offered by<br />
the end of the first year of operation. As the bereavement client<br />
census increases after one year, full-time staff will be employed.<br />
This will be measured via a signed declaratory <strong>state</strong>ment by the<br />
applicant.<br />
17. The applicant will commit to the provision of programs <strong>for</strong> the<br />
Hispanic and other minority populations which will include<br />
support from or involvement of bilingual staff, translated literature,<br />
training on cultural differences and competencies and flexible<br />
programming to meet their unique needs. Hospice staffing will<br />
reflect the racial and ethnic mix of the local community served.<br />
This will be measured via a signed declaratory <strong>state</strong>ment by the<br />
applicant.<br />
18. The applicant will develop a community resource library during the<br />
first year of the proposed hospice‟s operation. The library will<br />
include various lay and professional education pieces related to<br />
chronic illness, death, dying and bereavement. This will be<br />
measured via a signed declaratory <strong>state</strong>ment by the applicant.<br />
19. The applicant commits that the Odyssey Vista<strong>Care</strong> Hospice<br />
Foundation will facilitate the provision of a children‟s bereavement<br />
camp in Florida by the end of the first year of operation, similar to<br />
what Odyssey currently provides via Odyssey‟s SkyCamp, Camp<br />
Healing Tree and Camp Odyssey. This will be measured via a<br />
signed declaratory <strong>state</strong>ment by the applicant.<br />
20. The applicant will have a minimum of at least three community<br />
education representatives, expanding community awareness of<br />
hospice services and educating local medical staff, community<br />
leaders and potential hospice patients as to the benefits of and<br />
availability of hospice care. Compliance with this condition will be<br />
measured via submission of an annual <strong>report</strong> confirming that at<br />
least three CER staff members are employed at the proposed new<br />
19
CON Action Numbers: 10061-10065<br />
service and active in the local community. Additionally, if<br />
approved, Odyssey will provide education, training and assistance<br />
in development of respite care policies, procedures and protocols to<br />
nursing homes.<br />
21. Satellite offices: Hospice Service Area 4A includes five counties:<br />
Baker; Clay; Duval; Nassau and St. Johns. Odyssey commits to<br />
the immediate development of its main office in Duval County and<br />
two satellite offices; one satellite in Clay County by the end of year<br />
one of operation and a second satellite office in Nassau County by<br />
the end of year two of the operation.<br />
22. The applicant commits to become accredited by the Joint<br />
Commission and the National Institute <strong>for</strong> Jewish Hospice by the<br />
end of its second year of operation.<br />
23. The applicant commits to medical directors assessing every patient<br />
on admission and providing visits in home or place of residence.<br />
Medical director to be board-certified in hospice and palliative care<br />
medicine or will apply <strong>for</strong> board-certification within five years of<br />
employment.<br />
24. The applicant commits that every patient will be contacted on a<br />
daily basis.<br />
25. The applicant commits to sponsoring two to four education<br />
seminars per year <strong>for</strong> physicians, long-term care facilities and<br />
ALFs. The focus of these seminars is to educate the local health<br />
care community on the provision of hospice services within ALFs<br />
and other long-term care facilities: a coordinated plan of care <strong>for</strong><br />
the patient, increased support <strong>for</strong> patient, family and facility staff,<br />
and the provision of equipment, medication and supplies.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063), a <strong>for</strong>-profit<br />
provider, proposes the establishment of a new hospice program in<br />
Hospice Service Area 4A, consisting of Baker, Clay, Duval, Nassau and<br />
St. Johns Counties. The applicant <strong>state</strong>s that it operates hospice<br />
programs in 10 <strong>state</strong>s: Cali<strong>for</strong>nia, Delaware, Illinois, Indiana, Maryland,<br />
Massachusetts, Michigan, Pennsylvania, Texas and Wisconsin. The<br />
applicant currently has no CON approved or licensed hospice programs<br />
in Florida. According to the applicant, it promotes a patient focused<br />
“Circle of <strong>Care</strong>” program strategy in which the patient and family <strong>for</strong>m<br />
the hub from which needs emanate. In this strategy, the applicant <strong>state</strong>s<br />
every patient will have dignity throughout the end-of-life process, pain<br />
will be controlled and wishes will be met. In addition, the applicant<br />
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CON Action Number: 10061-10065<br />
<strong>state</strong>s commitment to what is <strong>state</strong>d as the fundamental principal upon<br />
which the program was founded - to die at home. The applicant<br />
proposes to specifically serve what it finds as the following two<br />
underserved groups – cancer patients age 65 and older and non-cancer<br />
patients age 65 and older.<br />
The applicant indicates that it will establish a main office in Clay County,<br />
near or in Orange Park.<br />
The applicant is proposing total project costs of $658,585 <strong>for</strong> building,<br />
equipment, project development and start-up costs.<br />
In its Schedule C, the applicant includes the following 20 itemized<br />
conditions:<br />
Initiated within the First Two Years<br />
1. Location in Clay County<br />
• Will locate the main office in Clay County<br />
• Measurement: Provide a physical location and street address in<br />
Clay County<br />
2. $50,000 outreach, promotion and expansion of hospice services in<br />
Clay County<br />
• Within six months of final approval of the CON, Seasons will<br />
meet with the Chairman of the Board of County Commissioners<br />
(and others as directed) on how best to establish a transparent<br />
process to allow <strong>for</strong> the donation and expenditure of $50,000 to<br />
promote outreach and education of hospice services.<br />
• Measurement: Status <strong>report</strong> to <strong>Agency</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong><br />
<strong>Administration</strong> regarding the process and procedures, with final<br />
notification of donated funds.<br />
3. $15,000 pilot project on outcome measures <strong>for</strong> two areas:<br />
infections and falls<br />
• Within six months of licensure, meet with representatives of the<br />
<strong>Agency</strong> and Department of Elder Affairs to review the process<br />
and procedures <strong>for</strong> the pilot program to collect data and<br />
development measures within the areas of infections and falls to<br />
design best practices.<br />
21
CON Action Numbers: 10061-10065<br />
• Upon approval of the process and procedures by the pilot<br />
project committee, Seasons will begin data collection and<br />
analysis, submitting the in<strong>for</strong>mation as scheduled to the<br />
Department of Elder Affairs.<br />
• By end of the second year, Seasons will complete the pilot<br />
program designed to <strong>report</strong> outcome measures to the <strong>Agency</strong><br />
and to the Department of Elderly fairs relating to the provision<br />
of hospice services.<br />
• Measurement: Periodic status <strong>report</strong>s as scheduled by the<br />
oversight committee, with a final <strong>report</strong> (in the third year), and<br />
recommended best practices <strong>for</strong> preventing infections and falls<br />
among hospice patients.<br />
4. Seek and maintain accreditation by The Joint Commission<br />
• Within the first two years, con<strong>for</strong>ming to the eligibility criteria<br />
<strong>for</strong> accreditation, begin the preparatory activities <strong>for</strong><br />
accreditation.<br />
• Measurement: Once accreditation is achieved, provide a copy of<br />
accreditation to the <strong>Agency</strong> and to the Department of Elder<br />
Affairs, and provide copies of renewals thereafter.<br />
Broad Community Benefits<br />
5. Seasons Hospice & Palliative <strong>Care</strong> Newsletter and the monthly<br />
news letter PharmSmart. These newsletters are designed to<br />
transmit the latest research and in<strong>for</strong>mation on hospice and<br />
palliative care, with a focus on professionals, physicians, physician<br />
assistants, nurse practitioners, and nurses (available to patients<br />
and families as well). The PharmSmart newsletter is written by a<br />
pharmacist and used <strong>for</strong> education <strong>for</strong> the community including<br />
physicians and pharmacists.<br />
• By the end of the first year have published at least one edition<br />
of each newsletter and made it available within the service area.<br />
• Measurement: Provide a copy of each issue of the newsletters<br />
to the <strong>Agency</strong> and to the Department of Elder Affairs.<br />
6. CEU provider <strong>for</strong> nursing and social workers<br />
• By the end of the second year, have established approval to<br />
provide continuing education units <strong>for</strong> licensed nurses and<br />
licensed social workers.<br />
22
CON Action Number: 10061-10065<br />
• Measurement: Provide the <strong>Agency</strong> with copy of the education<br />
provider number from the Florida Board of Nursing as well the<br />
Florida Board of Clinical Social Work, Marriage and Family<br />
Therapy, and Mental <strong>Health</strong> Counseling and schedule of<br />
courses, days and times.<br />
7. Voluntary submission of county level data to the Department of<br />
Elder Affairs and to The <strong>Agency</strong> on admissions by age, disease<br />
categories, place of admission, time to assessment, time to<br />
enrollment, length of stay, and visits<br />
• By the end of the second year, provide county level data to the<br />
Department of Elder Affairs.<br />
• Measurement: Submission of county level data defined above.<br />
8. 2.5 percent of admissions <strong>for</strong> uncompensated care<br />
• Measurement: Confirmed by the annual <strong>report</strong> to the<br />
Department of Elder Affairs.<br />
Special Programs<br />
9. Palliative radiation<br />
• Provide palliative radiation as prescribed in the plan of care.<br />
• Measurement: Report annually to the <strong>Agency</strong> the numbers of<br />
patients and numbers of treatment receiving palliative<br />
radiation.<br />
10. Palliative chemotherapy<br />
• Provide palliative chemotherapy as prescribed in the plan of<br />
care.<br />
• Measurement: Report annually to the <strong>Agency</strong> the numbers of<br />
patients and numbers of treatment receiving palliative<br />
chemotherapy.<br />
11. Ventilator-dependent in home care to permit the person to die on<br />
the ventilator, which differs from compassionate weaning<br />
• Provide ventilator-in-home care to hospice patients as<br />
prescribed in the plan of care.<br />
• Measurement: Report annually to the <strong>Agency</strong> the numbers of<br />
patients who received in-home care on a ventilator.<br />
23
CON Action Numbers: 10061-10065<br />
12. Kangaroo Kids-pediatric program <strong>for</strong> terminally ill children<br />
• Provide the program designed <strong>for</strong> terminally ill children.<br />
• Measurement: Report annually to the <strong>Agency</strong> the numbers of<br />
pediatric patients treated.<br />
13. Kangaroo Camp at Florida Resort <strong>for</strong> terminally ill children and<br />
families<br />
• By the end of the second year, have scheduled a Kangaroo<br />
Camp.<br />
• Measurement: Provide notification to the <strong>Agency</strong> of the<br />
scheduled camp and in<strong>for</strong>mation on location.<br />
14. A Touch <strong>for</strong> All Seasons-Alzheimer's Disease and other dementia<br />
• Implement the program.<br />
• Measurement: Report annually to the <strong>Agency</strong> on the numbers<br />
of patients enrolled in the A Touch <strong>for</strong> All Seasons.<br />
15. Partnership in Caring-nursing home program, education of facility<br />
staff<br />
• Implement the program<br />
• Measurement: Report annually to the <strong>Agency</strong> on the numbers<br />
of facilities participating in the program and the names of those<br />
facilities and the numbers of staff educated at those facilities.<br />
16. Music Therapy Program-provided by a music therapist employed<br />
by the hospice and part of the care team<br />
• Provide music therapy as a standard core service as prescribed<br />
in the plan of care.<br />
• Measurement: Report annually the number of patients who<br />
received music therapy and the number of music therapy visits<br />
delivered.<br />
17. Dieticians employed by the hospice and part of the care team<br />
• Employ one more dieticians (based on staffing ratios).<br />
• Measurement: Report the number of dieticians employed<br />
annually to the <strong>Agency</strong>.<br />
24
Operational Initiatives <strong>for</strong> Enhanced Quality<br />
CON Action Number: 10061-10065<br />
18. Implement and maintain electronic medical records<br />
• Implement the electronic medical record.<br />
• Measurement: Status <strong>report</strong> to <strong>Agency</strong> on the use of the<br />
electronic medical records.<br />
19. Call Center - 24 hours a day, seven days a week, staffed with<br />
Seasons employees, Seasons operates its own call center, fully<br />
integrated, <strong>for</strong> the hospice in 4A, and fully integrated with the<br />
electronic medical record <strong>for</strong> real time responses-tracking, and<br />
assignment of assessments.<br />
• Integrate hospice program in Service Area 4A <strong>for</strong> ongoing<br />
operations.<br />
• Measurement: Report the number of calls by day of week and<br />
time of day by month and response time to calls with status of<br />
admissions.<br />
20. Local Advisory Board - guide identification of needs, review<br />
locations <strong>for</strong> access points, branch offices, and inpatient capability<br />
• By the end of the first year, establish an advisory board.<br />
• Measurement: Provide the <strong>Agency</strong> with names of board<br />
members and roles and responsibilities of the board members,<br />
terms of service, and schedule of meetings. For ongoing<br />
operations, provide copies of meeting minutes and <strong>report</strong>s on<br />
activities.<br />
United Hospice of Florida, Inc. (CON #10064), a <strong>for</strong>-profit provider,<br />
proposes the establishment of a new hospice program in Hospice Service<br />
Area 4A, consisting of Baker, Clay, Duval, Nassau and St. Johns<br />
Counties.<br />
The parent, United <strong>Health</strong> Services, Inc. (UHS), is a member of the UHS-<br />
Pruitt family of companies which has its corporate office in Norcross,<br />
Georgia. UHS-Pruitt Corporation was founded in 1969 as the Toccoa<br />
Nursing Center in North Georgia. UHS is a holding company which owns<br />
and/or operates, through its subsidiaries, 71 long-term care facilities, 25<br />
hospice programs (in Georgia, South Carolina and North Carolina), 13<br />
25
CON Action Numbers: 10061-10065<br />
home health care agencies, five pharmacies, a health care management<br />
company, a nutritional services company, a clinical services company, a<br />
medical supply company and 14 SOURCE offices 4 . Presently, neither the<br />
applicant nor the parent has licensed or CON approved hospice programs<br />
in Florida.<br />
The applicant proposes a main office in Duval County, in the City of<br />
Jacksonville, and two satellite offices in rural areas of Hospice Service<br />
Area 4A – a Baker County office to be opened immediately upon licensure<br />
and a Nassau County office to be opened by the end of the second year of<br />
operation. The applicant also proposes to become a member of and<br />
partner with the St. Johns Rural <strong>Health</strong> Network 5 . According to what the<br />
applicant calls its in-depth market field survey and analysis ef<strong>for</strong>ts, it<br />
has identified the populations it believes are in greatest need of hospice<br />
services in the area and <strong>state</strong>s greater emphasis will be directed to the<br />
following: rural areas that are currently underserved by existing hospice<br />
providers, outreach to the African American community, outreach to the<br />
homeless and mentally ill populations and outreach to the non-cancer<br />
terminally-ill populations.<br />
The applicant is proposing total project costs of $251,232.72 <strong>for</strong><br />
equipment, project development and start-up costs.<br />
In its Schedule C, the applicant includes a brief conditions <strong>state</strong>ment<br />
and itemizes the following 10 specific conditions:<br />
United Hospice of Florida, Inc. - Conditions of the Application,<br />
Subdistrict 4A, Florida<br />
United Hospice of Florida <strong>state</strong>s that “reflective of its commitment to<br />
serve any and all terminally-ill residents of Subdistrict 4A, UHF is willing<br />
to accept any such conditions on its certificate of need based on any<br />
representations made throughout this document. The applicant will<br />
provide all required core components of hospice care set <strong>for</strong>th by<br />
Medicare conditions of participation as well as Florida hospice licensure<br />
requirements including the provision of all four levels of service (routine,<br />
continuous care, general inpatient and respite) to all types of patients<br />
without regard to race, ethnicity, gender, age, religious affiliation,<br />
4 The State of Georgia & UHS-Pruitt websites indicate UHS-Pruitt subsidiary Uni<strong>Health</strong> Solutions<br />
oversees UHS participation in SOURCE, which the State of Georgia‟s Medicaid long-term care diversion<br />
program.<br />
5 According to the Florida Department of <strong>Health</strong>, Office of Rural <strong>Health</strong>, Baker and Nassau Counties<br />
are classified by the State of Florida as rural counties, pursuant to Florida Statutes 381.0406 and<br />
these two counties are among the counties within the St. Johns River Rural <strong>Health</strong> Network.<br />
http://www.doh.<strong>state</strong>.fl.us/Work<strong>for</strong>ce/Rural<strong>Health</strong>/ruralhlthnetworks.htm<br />
26
CON Action Number: 10061-10065<br />
diagnosis, financial status, insurance status or any other discriminating<br />
factor. Specific conditions to be met by United Hospice of Florida, if<br />
awarded a CON to provide hospice services to Subdistrict 4A residents,<br />
are as follows:<br />
1. United Hospice Home and Community Based Services Provider:<br />
Upon CON approval, United Hospice's ultimate parent, UHS, will<br />
develop, in conjunction with United Hospice, UHS' family of<br />
services and companies in Subdistrict 4A and will enhance the<br />
hospice services available to area residents by making such<br />
services available not only to United Hospice's patients, but also to<br />
any other existing hospice provider who wishes to contract <strong>for</strong><br />
such services. The UHS family of services and companies include<br />
United Home <strong>Care</strong>, United Medical, United Pharmacy Services and<br />
United Clinical Services. This will be measured by a signed<br />
declaratory <strong>state</strong>ment submitted by United Hospice to the <strong>Agency</strong>.<br />
2. African American Outreach: Reflective of its commitment to<br />
enhancing access to the end-of-life care of African American<br />
residents in Subdistrict 4A, the applicant has conditioned approval<br />
of its application on the provision it will implement and maintain<br />
an African American Outreach Program.<br />
• A staff member will be responsible <strong>for</strong> the outreach initiatives.<br />
This individual's objective will be to coordinate staff activities,<br />
plan events and serve as a key contact within community<br />
leaders.<br />
• United Hospice will <strong>for</strong>m a planning and outreach team<br />
consisting of staff, volunteers and community members. This<br />
team will provide support <strong>for</strong> the staff person assigned primary<br />
responsibility <strong>for</strong> outreach ef<strong>for</strong>t.<br />
• United Hospice will host listening sessions with African<br />
American leaders, African American clergy and other members<br />
of the African American community to develop an<br />
understanding of attitudes and beliefs regarding end-of-life<br />
care. Some of these organizations will include but are not<br />
limited to:<br />
• Local NAACP branches<br />
• Jacksonville Urban League<br />
• Black Chamber of Commerce<br />
• Jacksonville City Mayor's office<br />
• State Representative Mia Jones<br />
• State Senator Tony Hill Sr.<br />
• State Representative Audrey Gibson<br />
27
CON Action Numbers: 10061-10065<br />
• Other City and County Leaders<br />
• Churches and other religious affiliated groups<br />
• Based on listening sessions, the applicant will develop a<br />
message, presentation and marketing materials that address<br />
needs and issues expressed by focus group respondents to<br />
ultimately deliver the message that addresses needs and<br />
concerns of the community.<br />
• United Hospice will continually assess existing tools and<br />
obtain or develop new resources as needed to provide<br />
culturally meaningful and appropriate educational<br />
opportunities <strong>for</strong> the African American community.<br />
• The applicant will provide ongoing comprehensive training<br />
<strong>for</strong> staff and volunteers who are actively involved in the<br />
outreach program. These individuals will plan quarterly<br />
town hall meetings with members of the community to<br />
engage, educate and energize individuals to begin end-of-life<br />
conversations in their organizations, congregations and so<br />
<strong>for</strong>th.<br />
• United Hospice will develop and maintain a calendar of<br />
events that address, support and celebrate African American<br />
issues, heritage and health care concerns. Staff members<br />
will attend various calendar events with the goal of making<br />
United Hospice of Florida the name and face known<br />
throughout the community.<br />
• The applicant will develop a census tracking tool to routinely<br />
track referrals generated by the outreach program to<br />
measure its ongoing success.<br />
• The applicant will <strong>report</strong> its admissions annually by race, to<br />
measure success and increase in percentage of African<br />
American admissions.<br />
This condition will be measured by a signed affidavit submitted to the<br />
<strong>Agency</strong>.<br />
3. Homeless Outreach: If awarded a certificate of need <strong>for</strong> the<br />
proposed project, United Hospice will partner with the ESHC to<br />
provide hospice services to Subdistrict 4A homeless individuals in<br />
either a residential or homeless shelter setting coordinated by<br />
ESHC. Specifically, United Hospice will accept the following<br />
conditions on its CON:<br />
• Continue active membership in the ESHC through attendance<br />
at monthly meetings and collaborating with coalition members<br />
in providing services to the homeless population.<br />
28
CON Action Number: 10061-10065<br />
• Provide hospice services to homeless population in shelters and<br />
assist with facility placement as appropriate. Shelters may<br />
include but are not limited to City Rescue Mission, Hubbard<br />
House, the Salvation Army, the Sulzbacher Center and Trinity<br />
Rescue Mission.<br />
• United Hospice will provide health screenings by a registered<br />
nurse once a month at one of the local not-<strong>for</strong>-profit social<br />
service organizations to be determined in collaboration with the<br />
ESHC.<br />
These homeless related activities will be measured by United Hospice's<br />
submission of a homeless activity <strong>report</strong> which will accompany its<br />
Annual Report to Department of Elder Affairs.<br />
4. Rural Areas Outreach: United Hospice has conditioned this<br />
application on the provision it will open a main office in<br />
Jacksonville plus two satellite offices in rural areas of Subdistrict<br />
4A as follows:<br />
• A Baker County office will open immediately upon licensure to<br />
serve the terminally-ill needs of Baker County residents.<br />
• A Nassau County office will open by the end of United Hospice's<br />
second year of operation.<br />
• Both the Baker and Nassau County offices will be centrally<br />
located to the population and will have a dedicated<br />
interdisciplinary team.<br />
• United Hospice will become a member of and will partner with<br />
the St. Johns Rural <strong>Health</strong> Network to improve the health of the<br />
communities in which United Hospice serves.<br />
This condition will be measured by a signed affidavit submitted to the<br />
<strong>Agency</strong>.<br />
5. Patients in Need of Continuous <strong>Care</strong>: United Hospice has<br />
conditioned this application on the provision it will provide, at a<br />
minimum, 2.5 percent of its patient days by the end of year two to<br />
continuous care which exceeds the <strong>state</strong> average, to the extent in<br />
which there is patient demand as determined by the<br />
interdisciplinary team. This condition will be measured via a<br />
signed declaratory <strong>state</strong>ment by United Hospice which may be<br />
supported via review of patient day <strong>report</strong>s by type and month<br />
produced by the applicant. United Hospice will monitor and<br />
annually <strong>report</strong> to the <strong>Agency</strong>, overall Subdistrict 4A continuous<br />
care percentage of patient days to determine success of its<br />
continuous care initiative.<br />
29
CON Action Numbers: 10061-10065<br />
6. CHAP Accreditation: United Hospice has conditioned approval of<br />
this application on the provision it will seek and obtain CHAP<br />
accreditation upon certification. This will be measured by<br />
submitting United Hospice's accreditation certificate to the <strong>Agency</strong><br />
upon receipt.<br />
7. Membership Organizations: Upon licensure, UHF will become a<br />
member of the following community organizations:<br />
• Florida Hospice and Palliative <strong>Care</strong>;<br />
• Jacksonville Regional Chamber of Commerce;<br />
• St. Johns County Chamber of Commerce;<br />
• Greater Nassau County Chamber of Commerce;<br />
• Clay County Chamber of Commerce; and<br />
• Baker County Chamber of Commerce.<br />
This will be measured by a signed affidavit submitted to the <strong>Agency</strong>.<br />
8. United Hospice Foundation: United Hospice Foundation will make<br />
available to Florida residents, its annual scholarship program<br />
targeted at those who are studying nursing, pharmacy or therapy<br />
with an interest in end-of-life care. The scholarship is available<br />
each year to four students in the amount of $2,000 <strong>for</strong> the school<br />
year. This will be measured by a signed affidavit submitted to the<br />
<strong>Agency</strong>.<br />
9. Staffing Ratios and Qualification: United Hospice will meet or<br />
exceed all NHPCO Guidelines <strong>for</strong> qualifications and staffing ratios<br />
<strong>for</strong> patient care staff. This will be measured by a signed<br />
declaratory affidavit submitted to the <strong>Agency</strong>.<br />
10. Pain Reduction: United Hospice will implement rapid pain<br />
management protocols to ensure that 75 percent of patients who<br />
<strong>report</strong> severe pain on a 0-10 scale will <strong>report</strong> a reduction to five or<br />
less by the end of the second day of care on the hospice program.<br />
This condition substantially exceeds the requirements of section<br />
400.60501, Florida Statutes. For patients that do not meet this<br />
pain reduction goal, such patient's plan of care will be evaluated<br />
within 48 hours by the medical director and a Pharm D.<br />
consultant to ensure that appropriate pain reduction measures are<br />
immediately implemented.<br />
30
CON Action Number: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065), a <strong>for</strong>-profit<br />
entity, proposes the establishment of a new hospice program in Hospice<br />
Service Area 4A, consisting of Baker, Clay, Duval, Nassau and St. Johns<br />
Counties.<br />
VITAS is a Florida-based entity, headquartered in Miami, Florida, that<br />
has been operating in Florida <strong>for</strong> over 30 years and has licensed hospice<br />
programs in the following eight hospice service areas: 4B (Flagler and<br />
Volusia Counties), 7A (Brevard County), 7B (Orange and Osceola<br />
Counties), 7C (Seminole County), 8B (Collier County), 9C (Palm Beach<br />
County), 10 (Broward County), and 11 (Miami-Dade and Monroe<br />
Counties). The applicant indicates that if the project is approved, its new<br />
hospice program in Hospice Service Area 4A will be operated under one<br />
of its three existing licenses. The applicant also indicates it operates 43<br />
hospice programs nationwide, spread among 16 <strong>state</strong>s and the District of<br />
Columbia. VITAS <strong>Health</strong>care Corporation‟s focus is on terminally ill<br />
patients and their families and is not a full continuum of health care<br />
services. As such, the applicant believes since its hospice services are<br />
not an adjunct to nursing home or home health services, its attention is<br />
not diluted by other product or business lines.<br />
The applicant proposes a main office in Duval County, in the City of<br />
Jacksonville, and two satellite offices in Hospice Service Area 4A, in<br />
Baker and Nassau Counties. The two satellites are to be created during<br />
the first year of operation. The applicant believes residents of Clay and<br />
St. Johns Counties will be adequately supported from the main office in<br />
Jacksonville. According to the applicant, based on its review of the<br />
Medicare Hospice Standard Analytical File 2007 (issued by the Centers<br />
<strong>for</strong> Medicare and Medicaid Services) and meetings/interviews by VITAS<br />
staff with local leaders, the following conclusions were reached in<br />
pinpointing underserved populations in Hospice Service Area 4A: noncancer<br />
patients 65 years of age and older, African-American patients and<br />
the lowest hospice admission rate (per 100 residents) in the hospice<br />
service area being in Baker County.<br />
The applicant is proposing total costs of $338,353 <strong>for</strong> equipment, project<br />
development costs and start-up costs.<br />
In its Schedule C, the applicant includes a brief conditions <strong>state</strong>ment<br />
and itemizes three primary conditions as follows:<br />
The intent of VITAS <strong>Health</strong>care Corporation is to provide high quality,<br />
cost-effective and coordinated services <strong>for</strong> its patients/families and the<br />
community-at-large. The applicant will make a meaningful contribution<br />
to the defined underserved areas of African-American persons and those<br />
31
CON Action Numbers: 10061-10065<br />
persons with non-cancer illnesses in need of hospice care. This will be<br />
accomplished through its proven experience and programming,<br />
successful operating model and assured via the conditions proposed by<br />
the applicant. VITAS <strong>Health</strong>care Corporation commits to the following<br />
core service, non-core service and operational/programmatic conditions<br />
identified below and commits to meet all of the requested <strong>report</strong>ing<br />
requirements and time frames as defined in Chapter 59C-1.013 and 59C-<br />
1.021, Florida Administrative Code.<br />
1. Percent of a particular population subgroup to be served.<br />
• The first population subgroup is defined as hospice patients in<br />
need of continuous care: VITAS <strong>Health</strong>care Corporation will<br />
provide at least three percent of its total patient days to<br />
continuous care by the end of year two. This will be measured<br />
via a signed declaratory <strong>state</strong>ment by VITAS <strong>Health</strong>care<br />
Corporation which may be supported via review of patient day<br />
<strong>report</strong>s by type and month produced by VITAS <strong>Health</strong>care<br />
Corporation.<br />
• The second population subgroup is defined as hospice patients<br />
with diagnosis other than cancer. The applicant will guarantee<br />
that at least 65 percent of patients admitted have non-cancer<br />
diagnoses. This will be measured via a signed declaratory<br />
<strong>state</strong>ment by VITAS <strong>Health</strong>care Corporation which may be<br />
supported via review of admission <strong>report</strong>s by patient diagnosis<br />
produced by VITAS <strong>Health</strong>care Corporation<br />
2. Special Programs: VHCF has conditioned the application on the<br />
provision it will meet or exceed the following quality and patient<br />
satisf<strong>action</strong> indicators:<br />
• Pain Control: On the first day of hospice care responsive<br />
patients will be asked to rate their pain on the 0-10 World<br />
<strong>Health</strong> Organization pain scale (severe pain to worst pain<br />
imaginable). A pain history will be created <strong>for</strong> each patient.<br />
These measures will be recorded in VITAS‟ proprietary<br />
in<strong>for</strong>mation management system, VITAS Exchange (or Wx") via<br />
a telephone call using the telephone keypad <strong>for</strong> data entry.<br />
These outcome measures will include greater than 70 percent of<br />
patients who <strong>report</strong> severe pain on a seven-10 scale will <strong>report</strong> a<br />
reduction to five or less within 48 hours. Florida Statutes<br />
400.60501 requires only a 50 percent reduction in 96 hours;<br />
this commitment set <strong>for</strong>th by VITAS far exceeds Florida<br />
statutory requirements and is a significant commitment to<br />
quality care.<br />
32
CON Action Number: 10061-10065<br />
• Death Attendance: VITAS <strong>Health</strong>care Corporation will attend at<br />
least 90 percent of all deaths to ensure patients do not die<br />
alone. This will be measured via a signed declaratory <strong>state</strong>ment<br />
by VITAS which may be supported via review of patient medical<br />
records.<br />
• Patient Family Satisf<strong>action</strong>: VITAS <strong>Health</strong>care Corporation will<br />
achieve an overall patient satisf<strong>action</strong> score of 90 percent or<br />
above on patient's family evaluation of care while under the care<br />
of VITAS. This is determined by a mail-in survey sent by VITAS<br />
to the patient's family and measured by recording all scores.<br />
• Discipline Specific Satisf<strong>action</strong>: VITAS <strong>Health</strong>care Corporation<br />
will achieve an overall registered nurse satisf<strong>action</strong> score of 90<br />
percent or above on patient's family satisf<strong>action</strong> with the VITAS<br />
nurse while under the care of VITAS. This is determined by a<br />
mail-in survey sent by VITAS to the patient's family and<br />
measured by recording all scores.<br />
• Pet Therapy: Implementation of a pet therapy program to begin<br />
immediately. PetPals is a program where screened dogs visit<br />
shut-ins, nursing homes, assisted living facilities adult day care<br />
center and Alzheimer patients. This program offers a visit with<br />
a pet to those in the community who may respond to the love<br />
and com<strong>for</strong>t of a pet therapy dog. VITAS has an affiliation with<br />
the Central Florida Toy Dog Club which has sister organizations<br />
throughout the <strong>state</strong>. Volunteers and their pets are trained to<br />
assist patients and their families in any setting.<br />
3. Other Conditions: VITAS <strong>Health</strong>care Corporation has conditioned<br />
its application on the provision it will meet or exceed the following<br />
operational and programmatic indicators:<br />
• Establish satellite hospice offices in Baker and Nassau Counties<br />
during the first year of operation.<br />
• Implement a Tele<strong>Care</strong> Program consisting of 24/7 nurse<br />
availability to begin immediately.<br />
• Establish a Local Ethics Committee to begin upon certification,<br />
as discussed in Schedule B Section E2 of this application.<br />
• Implementation of <strong>Care</strong>PlanlT, a handheld bedside clinical<br />
in<strong>for</strong>mation system, by the end of the second year of operation.<br />
<strong>Care</strong>PlanlT is discussed in Schedule B Section E2.<br />
• Provide palliative radiation, chemotherapy and transfusions as<br />
appropriate <strong>for</strong> treating symptoms.<br />
• Provision of hospice services 24 hours a day, seven days a week<br />
as indicated by the patient's medical condition.<br />
• VITAS <strong>Health</strong>care Corporation will admit all eligible patients<br />
without regard to their ability to pay.<br />
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CON Action Numbers: 10061-10065<br />
• Commit to having every patient being assessed by a physician<br />
upon admission to the hospice. Medical directors provide<br />
patient visits in their residence.<br />
• Medical directors must also be board-certified in hospice or<br />
palliative care medicine, or apply <strong>for</strong> board-certification within<br />
five years of employment.<br />
• RNs are encouraged to become certified in hospice and palliative<br />
care nursing. By the second year of operation, 50 percent of all<br />
supervisory nurses will attain such certification.<br />
• Chaplains are Masters of Divinity, demonstrated by completion<br />
of accredited CPE program.<br />
• Social workers are Master's level or licensed clinical social<br />
workers.<br />
• Designate a hospice representative to provide community<br />
outreach, promote hospice awareness and enhance access to<br />
African-American individuals in Subdistrict 4A.<br />
• A physician will serve as a member on every care team and<br />
provide patient visits as required.<br />
• Although bereavement services are generally provided to the<br />
family <strong>for</strong> one year after the death of the patient, services will be<br />
available beyond one year, if needed.<br />
• VITAS agrees that it will not solicit and will not accept<br />
donations from hospice patients, their families or the general<br />
community. VITAS will provide alternative hospice and charity<br />
in<strong>for</strong>mation to VITAS patients and their families and members<br />
of the community seeking to donate funds to hospice services.<br />
• Establish a clinical pastoral education program to begin<br />
immediately. The program description is found in TAB 10.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution in the amount of $300,000 to Florida State College<br />
at Jacksonville to fund an endowed teaching chair,<br />
scholarships, and the Northeast Florida Initiative <strong>for</strong> Nursing<br />
Work<strong>for</strong>ce Diversity. This will be initiated during its first year of<br />
licensure and will be measured via a signed declaratory<br />
<strong>state</strong>ment by VITAS and evidence of funds transferred. The<br />
correspondence between VITAS and Florida State College<br />
describing the uses of the donation is found in TAB 11.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution to United Way of Northeast Florida in the amount<br />
of up to $500,000 during the first three years of licensure. The<br />
United Way will serve as a charitable advisor to VITAS<br />
<strong>Health</strong>care Corporation identifying not-<strong>for</strong>-profit organizations<br />
34
CON Action Number: 10061-10065<br />
in need of funding. The charitable contribution condition will<br />
be measured via a signed declaratory <strong>state</strong>ment by VITAS and<br />
evidence of funds transferred. The correspondence between<br />
VITAS and United Way of Northeast Florida describing the<br />
donation process is found behind TAB 11.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution to the Jacksonville Urban League in the amount of<br />
$50,000 during the first year of licensure. The contribution will<br />
be used to expand several health and quality-of-life initiatives<br />
currently in place at Jacksonville Urban League <strong>for</strong> a client base<br />
which is predominantly the underserved African American<br />
population. The charitable contribution condition will be<br />
measured via a signed declaratory <strong>state</strong>ment by VITAS and<br />
evidence of funds transferred. The correspondence between<br />
VITAS and the Jacksonville Urban League describing the uses<br />
of the donation is found in TAB 11.<br />
ALL: None of the applicants proposed to condition to voluntary <strong>report</strong>ing<br />
of the <strong>Agency</strong>‟s „Family Evaluation of Hospice <strong>Care</strong> (FEHC) Satisf<strong>action</strong><br />
Survey‟ found at the Florida<strong>Health</strong>Finder.gov website. Hospice programs<br />
are required by federal and <strong>state</strong> law to provide services to everyone<br />
requesting them and there<strong>for</strong>e the <strong>Agency</strong> would not place conditions on<br />
a program to provide legally required services. Rule 59C-1.013(4) Florida<br />
Administrative Code contains condition compliance <strong>report</strong>ing criteria<br />
that the <strong>Agency</strong> uses <strong>for</strong> an approved CON that has conditions.<br />
D. REVIEW PROCEDURE<br />
The evaluation process is structured by the certificate of need review<br />
criteria found in Section 408.035, Florida Statutes, rules of the State of<br />
Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code.<br />
These criteria <strong>for</strong>m the basis <strong>for</strong> the goals of the review process. The<br />
goals represent desirable outcomes to be attained by successful<br />
applicants who demonstrate an overall compliance with the criteria.<br />
Analysis of an applicant's capability to undertake the proposed project<br />
successfully is conducted by evaluating the responses provided in the<br />
application, and independent in<strong>for</strong>mation gathered by the reviewer.<br />
Applications are analyzed to identify various strengths and weaknesses<br />
in each proposal. If more than one application is submitted <strong>for</strong> the same<br />
type of project in the same district (subdistrict or service planning area),<br />
applications are comparatively reviewed to determine which applicant<br />
best meets the review criteria.<br />
35
CON Action Numbers: 10061-10065<br />
Section 59C-1.010(3)(b), Florida Administrative Code, prohibits any<br />
amendments once an application has been deemed complete. The<br />
burden of proof to entitlement of a certificate rests with the applicant. As<br />
such, the applicant is responsible <strong>for</strong> the representations in the<br />
application. This is attested to as part of the application in the<br />
certification of the applicant.<br />
As part of the fact-finding, the consultant, Steve Love, analyzed the<br />
application in its entirety with consultation from financial analyst,<br />
Derron Hillman, who evaluated the financial data.<br />
E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA<br />
The following indicates the level of con<strong>for</strong>mity of the proposed projects<br />
with the criteria found in Florida Statutes, Sections 408.035 and<br />
408.037; applicable rules of the State of Florida, Chapter 59C-1 and<br />
59C-2, Florida Administrative Code.<br />
1. Fixed Need Pool<br />
a. Does the project proposed respond to need as published by a fixed<br />
need pool? Chapter 59C-1.008, Florida Administrative Code and<br />
Chapter 59C-1.0355, Florida Administrative Code.<br />
In Volume 35, Number 39 of the Florida Administrative Weekly, dated<br />
October 2, 2009, the <strong>Agency</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong> <strong>Administration</strong> published a<br />
need <strong>for</strong> one hospice program in AHCA Hospice Service Area 4A (Baker,<br />
Clay, Duval, Nassau and St. Johns Counties) <strong>for</strong> the January 2011<br />
Hospice Planning Horizon. Hospice Service Area 4A is currently served<br />
by the following three licensed hospice providers: Community Hospice of<br />
Northeast Florida, Inc.; Haven Hospice and Heartland Home <strong>Health</strong> <strong>Care</strong><br />
and Hospice (the latter being licensed effective 9/6/07).<br />
Each co-batched applicant is applying in response to published need <strong>for</strong><br />
a hospice program in Hospice Service Area 4A (Baker, Clay, Duval,<br />
Nassau and St. Johns Counties). However, how each co-batched<br />
applicant addresses existing unmet need to support their project is<br />
briefly described below.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) relies<br />
upon the <strong>Agency</strong>‟s <strong>state</strong>d fixed need pool <strong>for</strong> one additional hospice<br />
program in the service area but also uses additional justification.<br />
36
CON Action Number: 10061-10065<br />
Compassionate <strong>Care</strong> provided a detailed description of the <strong>Agency</strong>‟s<br />
hospice need calculation on pages 36-41. Beginning at the middle of<br />
page 41 and continuing to the middle of page 45, the applicant compares<br />
the service area with the <strong>state</strong> projections by diagnostic category and age<br />
(i.e. cancer age under 65 and 65 and over, and „all other‟ age under 65<br />
and 65 and over). They conclude that the service area is underserved in<br />
all categories especially in the age 65 and over „other‟ category. Since<br />
there is a need <strong>for</strong> one program, this is not an unexpected result.<br />
The applicant‟s Table 1 (CON #10061, page 11) documented the <strong>state</strong>‟s<br />
annual hospice “unmet need” (actual admissions minus projected<br />
admissions) by planning horizon and service area from January 2006 –<br />
January 2011. This table demonstrates that Service Area 4A is<br />
consistently showing need in that the gap between current hospice<br />
admissions and projected horizon year admissions has consistently been<br />
above 350 (ranging from 676 to 1,118). Every planning horizon<br />
calculation would result in need <strong>for</strong> a new hospice, except that the<br />
service area has had approved hospices in operation <strong>for</strong> less than two<br />
years during several of these periods. Service Area 4A and Service Area<br />
11 (Miami-Dade and Monroe Counties) are the only service areas where<br />
this has occurred.<br />
Compassionate <strong>Care</strong> indicates that it undertook an extensive community<br />
assessment to determine unmet hospice need. This included phone<br />
calls, personal meetings and a survey questionnaire sent to 242<br />
providers. The application‟s Appendix P–Community Assessment Survey<br />
Instrument includes the survey cover letter, needs questionnaire and a<br />
mailing list of local hospitals, nursing homes, assisted living facilities,<br />
end-stage renal disease centers, adult day care, and adult family home<br />
care facilities. According to the applicant, the survey responses were<br />
anonymous and included a response rate of approximately four percent.<br />
This is a low response rate. Compassionate <strong>Care</strong> indicated that the a<br />
specific unmet need was not identified; there was need <strong>for</strong> support<br />
services <strong>for</strong> staff in nursing homes after they experienced a loss of a longterm<br />
resident and some respondents identified patients‟ need <strong>for</strong> IV pain<br />
medications but it was not clear from the comments whether the services<br />
were not available or whether the need was a consistent need of the<br />
facility‟s hospice patients. The respondents welcomed Compassionate<br />
<strong>Care</strong>‟s potential entry into the local hospice market.<br />
Compassionate <strong>Care</strong> indicates that numerous brochures about the<br />
applicant‟s hospice program were sent to providers in the area. The<br />
applicant has 15 general marketing brochures and five pediatrics<br />
brochures.<br />
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CON Action Numbers: 10061-10065<br />
According to the applicant, written letters of support were “thwarted”<br />
because few individuals were willing or interested in getting into the<br />
“politics” of CON. Potential supporters also indicated they did not want<br />
to upset existing providers or were overwhelmed by the number of<br />
applicants and decided not to support anyone. The <strong>Agency</strong> notes the<br />
applicant submitted the fewest letters of support of any co-batched<br />
applicant.<br />
Compassionate <strong>Care</strong> contends that the hospice service area is<br />
geographically challenged to meet hospice need. The applicant <strong>state</strong>s<br />
that its discussions with existing health care providers and surveys<br />
demonstrate a full range of services and support activities in the market<br />
and that the existing Community Hospice of Northeast Florida has the<br />
greatest number of office locations. However, there are no offices in Clay<br />
or Baker County, there is one in Nassau and multiple offices in Duval<br />
and St. Johns. Compassionate <strong>Care</strong> <strong>state</strong>s that a significant number of<br />
potential cases are not receiving care most likely due to geographic<br />
access issues and/or provider resource constraints. While this is not<br />
well documented, there is a projected need <strong>for</strong> an additional program and<br />
the applicant provides a map of the service area‟s existing and its<br />
proposed locations on page 48 of the application. United Hospice (CON<br />
#10064) and VITAS (CON #10065) make similar claims concerning<br />
rural area access issues in the hospice service area.<br />
Compassionate <strong>Care</strong> is more specific than any co-batched applicant<br />
regarding the three planned locations of its hospice offices (Duval, Clay<br />
and St. Johns Counties). The applicant conditions <strong>for</strong> these locations, by<br />
zip code.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) contends that in addition<br />
to the <strong>Agency</strong>-defined need <strong>for</strong> an additional hospice program in Hospice<br />
Service Area 4A, there are “special and not normal” circumstances that<br />
warrant the approval of another hospice program. The applicant <strong>state</strong>s<br />
the following are “special and not normal” circumstances:<br />
(a) Hospice Service Area 4A consistently being underserved by existing<br />
hospices in light of utilization rates consistently lower than the<br />
Florida average hospice utilization rate;<br />
(b) The consistently underserved patient group: cancer patients aged<br />
65 years and older;<br />
(c) The consistently underserved patient group: non-cancer patients<br />
aged 65 years and older, and<br />
(d) The consistently underserved patient group: non-cancer patients<br />
under age 65.<br />
38
CON Action Number: 10061-10065<br />
The applicant reaches this conclusion based the following assertions.<br />
First, the applicant presents a Hospice Service Area 4A profile, with<br />
demographic data (total population, age cohort and density by county<br />
assessments), local area health data (total area deaths, major causes of<br />
death, a chronic disease three-year age-adjusted mortality rate<br />
assessment, county death data comparisons), limitations of the current<br />
hospice system (underserved residents and underserved patient groups<br />
by age and diagnosis). Second, the applicant presents a discussion of<br />
the rationale behind the project, with an explanation of the applicant‟s<br />
quality and experience. Third, the applicant presents a quantitative need<br />
argument and a market <strong>for</strong>ecast. These conclusions are discussed<br />
briefly below.<br />
Odyssey uses the <strong>Agency</strong>‟s „Population Estimates‟ September 2008<br />
publication which indicates that Hospice Service Area 4A‟s total<br />
population is projected to increase from 1,389,435 in 2009 to 1,460,081<br />
by 2012, an increase of 70,646 residents. This is an increase of about<br />
5.1 percent compared to the <strong>state</strong>‟s projected population growth of about<br />
4.9 percent. The service area‟s age 65 and over population is projected to<br />
increase from 167,735 in 2009 to 192,273 in 2012, an increase of 24,538<br />
residents or about 14.6 percent compared to 9.6 percent <strong>for</strong> the <strong>state</strong>.<br />
Hospice Service Area 4A by County<br />
Land Area & Population Density<br />
County Land Area (Square Miles) Population Per Square Mile<br />
Baker 585.21 38<br />
Clay 601.11 234.4<br />
Duval 773.67 1006.3<br />
Nassau 651.55 88.4<br />
St. Johns 609.01 202.2<br />
Florida Total 53,926.82 296.4<br />
Source: CON Application #10062 from U.S. Census Bureau, 2000 Census.<br />
The applicant shows population density, by each Hospice Service Area 4A<br />
county, is as follows, from most to least dense: Duval; Clay; St. Johns;<br />
Nassau and Baker. The Population Density included in <strong>Agency</strong>‟s<br />
Hospital Beds & Services publication of July 2009, shows the same order<br />
with increased population density <strong>for</strong> July 2009.<br />
39
CON Action Numbers: 10061-10065<br />
POPULATION DENSITY<br />
Hospice Service Area 4A Counties<br />
July<br />
July 2009<br />
Square 2009 Population<br />
County Miles Population Density<br />
Baker 585 26,179 44.73<br />
Clay 601 192,458 320.18<br />
Duval 774 916,153 1,184.12<br />
Nassau 652 71,504 109.74<br />
St. Johns 609 183,141 300.72<br />
State Total 53,927 19,115,269 354.46<br />
Source: <strong>Agency</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong> <strong>Administration</strong> Hospital Beds & Services –<br />
July 2009 Batching Cycle.<br />
Odyssey <strong>state</strong>s that it has extensive experience in providing hospice<br />
services in rural areas and provides a detailed discussion of their<br />
Charleston, South Carolina; Temple, Texas and Savannah, Georgia<br />
services to residents in rural areas. Odyssey concludes that it is<br />
prepared to address similar rural challenges in Baker and Nassau<br />
Counties. The applicant conditions to have satellite offices in Nassau<br />
County by the end of year two of operation and Clay County to serve<br />
Baker County by the end of year one of operation. The applicant<br />
contends this will offer a measure of convenience and efficiency <strong>for</strong><br />
Odyssey staff and also provide a means to offer enhanced educational<br />
opportunities <strong>for</strong> residents to be aware of hospice within the community.<br />
Concerning local area health data, the applicant notes rising service area<br />
death rates <strong>for</strong> all causes from 2004 through 2008, with a death rate rise<br />
of 6.2 percent compared to a <strong>state</strong>wide death rate of 1.3 percent. The<br />
applicant further notes that while cancer and heart disease accounted<br />
<strong>for</strong> approximately 60 percent of 2008 deaths in the hospice service area,<br />
this leaves an array of other life-limiting and terminal diagnoses that a<br />
hospice must be prepared to address. The applicant believes its<br />
experience especially qualifies it to meet the needs of patients with<br />
traditional and non-traditional diagnoses. The applicant assesses the<br />
three-year age-adjusted mortality rates, by various chronic disease<br />
categories, from 2006 through 2008, and also just <strong>for</strong> the year 2008, in<br />
attempting to anticipate likely causes of death in each of the counties<br />
within the hospice service area.<br />
The applicant shows that <strong>for</strong> the October 2009 Batching Cycle, Hospice<br />
Service Area 4A had the next to lowest hospice penetration rate of any of<br />
the 27 hospice service areas <strong>state</strong>wide. The applicant also shows that<br />
hospice penetration in 4A has been persistently below the <strong>state</strong> hospice<br />
40
CON Action Number: 10061-10065<br />
penetration rate <strong>for</strong> each batching period since April 2004. Odyssey<br />
compares the <strong>state</strong> penetration rate with Hospice Service Area 4A‟s to<br />
demonstrate that the patient groups that are underserved include cancer<br />
patients aged 65 years and older, non-cancer patients under age 65 and<br />
non-cancer patients age 65 and older.<br />
With regard to the applicant‟s proposed service to under-served patients<br />
as a “special and not normal” circumstance, Odyssey described its<br />
<strong>Care</strong>Beyond Program, which includes specialized hospice protocols<br />
unique to specific diseases including cancer, COPD, congestive heart<br />
failure and dementia. The applicant conditions <strong>for</strong> the implementation of<br />
this specific protocol system. The applicant describes in detail how<br />
<strong>Care</strong>Beyond applies to a cancer, COPD, congestive heart failure and<br />
dementia diagnosis.<br />
The applicant also indicates that interviews in the hospice service area<br />
revealed other needs, including: local interest in psycho-social support<br />
and hospice care in nursing homes, hospice education at ALFs,<br />
education on end-of-life decisions, continuous care when death is<br />
imminent, and patient admission with a physician order within three<br />
hours (24 hours a day, seven days a week). The applicant does not<br />
condition <strong>for</strong> admission to the program within three hours of a physician<br />
order.<br />
With regard to the applicant‟s quantitative need and a market <strong>for</strong>ecast,<br />
the applicant utilizes three methods to assess quantitative admission<br />
estimates – the <strong>Agency</strong>‟s need projection, the <strong>Agency</strong>‟s need projection<br />
modified using the 4A admission rate <strong>for</strong> cancer patients under age 65<br />
and a third approach based on a continuation of Service Area 4A‟s<br />
historic growth rates in hospice admissions, population growth and aging<br />
population. The applicant <strong>state</strong>s that these factors support a future<br />
overall increase in hospice penetration.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063), indicates that<br />
Marcia Norman, President and Founder of the parent organization,<br />
traveled on two occasions to Florida and spent several days each trip<br />
meeting with Service Area 4A hospital discharge planners, hospital<br />
administrators, nursing home operators, directors of assisted living<br />
facilities, physicians, providers, and community residents. The applicant<br />
indicates that from these meetings, Ms. Norman found several benefits<br />
that <strong>for</strong>m the objective <strong>for</strong> their proposal. These include providing<br />
greater numbers of access points to increase hospice utilization, make<br />
available specialized programs with proven benefits to hospice patients<br />
such as „Touch <strong>for</strong> All Seasons‟, „Kangaroo Kids‟ and „Tender Legal <strong>Care</strong>‟.<br />
Seasons will also provide a 24-7 call center to ensure residents‟ needs<br />
41
CON Action Numbers: 10061-10065<br />
are met and provide area providers, such as nursing homes, assisted<br />
living facilities and senior centers access to resources that develop longterm<br />
relationships with the hospice teams. They will also provide<br />
educational and promotional events to make hospice care more visible as<br />
part of the service area‟s health care delivery system. Seasons indicates<br />
a need to involve other providers in the provision of hospice inpatient<br />
care.<br />
Seasons provides a detailed description of the service area 4A population<br />
by county <strong>for</strong> 2008 and 2007 deaths, including projected population<br />
estimates through 2012. The applicant indicates that its analysis shows<br />
the service area‟s „Cancer over 65‟ and „Other over 65‟ groups are<br />
underserved compared to the <strong>state</strong> average. Seasons also finds that Clay<br />
County residents aged 65 years and older have a higher in-hospital death<br />
rate at 12.6 per thousand compared to the service area average at 11.5<br />
per 1,000 aged 65 years and older. The applicant notes that Baker<br />
County at 13.5 and Duval County at 12.1 per thousand population age<br />
65 and older also have a higher in-hospital death rate per thousand than<br />
the service area. However, Baker County had only 54 deaths and is<br />
located at the western border of the service area and Duval has three<br />
existing hospice offices, so the applicant rules them out as a location <strong>for</strong><br />
an office. Clay County residents‟ death rate <strong>for</strong> eight illness categories is<br />
higher than Nassau and St. Johns‟ Counties and higher than the <strong>state</strong>‟s<br />
rates in seven of the eight. These factors indicate to the applicant that<br />
Clay County is underserved, thus Seasons plans to locate in Clay<br />
County, in or near Orange Park.<br />
Seasons next discussed Service Area 4A population projections<br />
indicating that from 2009 to 2012 the population age 65 and over will<br />
increase from 165,282 to 187,423 or by 13.4 percent, compared to the<br />
total population increase from 1,383,913 in 2009 to 1,446,196 or by 4.5<br />
percent. By year two (ending in December 2012) Seasons projects 615<br />
admissions, with 35,690 patient days and an average length of stay<br />
(ALOS) of 56 days. This actually computes to a 58 day ALOS. The<br />
applicant expects to capture a six percent market share by year one<br />
(ending December 2011) and a nine percent market share by year two<br />
(ending December 2012). Seasons also provides a detailed description of<br />
Florida start up hospice admissions in support of its projections. The<br />
applicant‟s projections appear to be somewhat reasonable based on the<br />
market shares captured by other new hospice programs that became the<br />
fourth hospice in the service area and began operations during and after<br />
42
CON Action Number: 10061-10065<br />
February 2005. However, the applicant concedes that initial market<br />
share capture rates can vary widely but <strong>state</strong>s its projections are also<br />
based on Season‟s national experience.<br />
Seasons places emphasis on its accreditation with the Joint Commission<br />
and conditions to have this program so certified. They also discussed the<br />
existing 4A hospice providers and competitors, noting that none have<br />
Joint Commission accreditation. Seasons notes that Haven Hospice has<br />
Community <strong>Health</strong> Accreditation Program (CHAP) and Accreditation<br />
Commission on <strong>Health</strong> <strong>Care</strong> (ACHC) accreditation 6 . The applicant<br />
indicates that it has Joint Commission accreditation on hospices in<br />
seven of the 10 <strong>state</strong>s it operates in and is in the process of obtaining<br />
accreditation in the remaining three <strong>state</strong>s. This compares to VITAS with<br />
five programs in Pennsylvania and two in Texas, Odyssey with one in<br />
Rhode Island and one in Texas; Compassionate <strong>Care</strong> with 12 programs<br />
(including home health agencies, one in Fort Lauderdale, Florida) and<br />
United Hospice with one in New York. VITAS has CHAP core hospice<br />
accreditation <strong>for</strong> its Miami hospice; Odyssey has two - Oklahoma City<br />
and Dallas; and Compassionate <strong>Care</strong> has 15 core hospice accreditations,<br />
none in Florida. The applicant <strong>state</strong>s that none of the competing<br />
hospices have ACHC accreditation.<br />
United Hospice of Florida, Inc. (CON #10064) compares Hospice<br />
Service Area 4A‟s penetration rate with the <strong>state</strong> average which shows<br />
that overall Service Area 4 was 7.7 percent below the <strong>state</strong> average.<br />
United contends that non-cancer patients of all ages appear to be<br />
particularly underserved. Non-cancer patients under age 65 and the age<br />
65 and over cancer cohorts are each 1.3 percent and the 65 and over<br />
non-cancer cohort 8.3 percent below the <strong>state</strong> average. According to the<br />
applicant, 73.3 percent of United‟s patients have a non-cancer diagnosis<br />
and its extensive experience along with its corporate resources give<br />
United Hospice an advantage to meet the hospice need of the area. The<br />
applicant contends that the following populations are underserved:<br />
African Americans, the homeless, terminally ill residents in rural outlying<br />
areas, patients needing continuous care, and patients with a terminally<br />
ill non-cancer diagnosis.<br />
Concerning African Americans, the applicant provides a December 2009<br />
18-page article from the Journal of Pain, Vol. 10, No. 12 (CON<br />
Application #10064, Tab 15-Racial and Ethnic Disparities in Pain:<br />
Causes of Unequal <strong>Care</strong>) that explores disparities in palliative care and<br />
overall hospice service nationwide. The applicant indicates that eight<br />
6 Accreditation status <strong>for</strong> competitors and existing Service Area 4A providers was confirmed with the<br />
<strong>Agency</strong>‟s Licensed Home <strong>Health</strong> Programs Unit.<br />
43
CON Action Numbers: 10061-10065<br />
professional staff of United spent three weeks in the service area meeting<br />
with community leaders and others. They conclude that greater hospice<br />
education and outreach is needed in the local African American<br />
community. The applicant further notes that in 2008, Duval County<br />
acute care hospitals discharged African American patients to hospice at a<br />
disproportionately lower rate (0.9 percent) compared to all other patients<br />
(1.8 percent). The applicant <strong>state</strong>s that had African Americans been<br />
discharged to hospice care at the same rate as non-African Americans,<br />
an additional 305 African Americans would have been so discharged.<br />
United also notes that within a five-mile radius of four major Duval<br />
County hospitals, there is an African American population ranging from<br />
29 to 60 percent. The applicant also provides a comparison of these<br />
facilities African American discharges to their overall discharges and<br />
discharges to hospice. United <strong>state</strong>s that in communities in which the<br />
African-American population exceeds 30 percent of total population, as is<br />
the case in Duval County, UHS patient days provided to African<br />
Americans exceed 46 percent of total patient days. For the 12 months<br />
ending October 31, 2009, more than 26 percent of UHS‟ total patient<br />
days were provided to African-Americans. The applicant indicates that<br />
16 of its 26 hospice programs provided 26 percent or more and five<br />
programs provided over 40 percent of their total admissions to African<br />
Americans. The applicant indicates this reflects its success in outreach<br />
concerning the African American population and expects similar ef<strong>for</strong>ts<br />
and results in reaching the African American community in the area, if<br />
the project is approved. United concludes this discussion by restating its<br />
proposed condition (#2) to implement and maintain an African-American<br />
Outreach Program and provides a list of groups and individuals that it<br />
will contact. Some of these include: local NAACP branches, Jacksonville<br />
Urban League, Black Chamber of Commerce, Jacksonville Mayor‟s Office,<br />
State Senator Tony Hill, Sr., and State Representatives Mia Jones and<br />
Audrey Gibson. There were no support letters from any of these entities<br />
or individuals.<br />
United <strong>state</strong>s that the Northeast Florida Center <strong>for</strong> Community Initiatives<br />
at the University of North Florida compiles an annual <strong>report</strong> of the Duval,<br />
Clay and Nassau Counties‟ homeless population <strong>for</strong> the Emergency<br />
Services and Homeless Coalition of Jacksonville, Inc. (ESHC) 7 . This<br />
<strong>report</strong> indicates that there were 18,393 homeless adults and children<br />
spread among the three counties in 2008, representing a 7.7 percent<br />
increase over the prior year. Of the 18,393 homeless individuals, 18,088<br />
7 The ESHC website indicates that it has 54 member agencies and is committed to coordinating ef<strong>for</strong>ts<br />
to raise, distribute and manage resources <strong>for</strong> preventing and ending homelessness. ESHC is the lead<br />
<strong>agency</strong> <strong>for</strong> Duval, Clay, Nassau and Baker Counties.<br />
44
CON Action Number: 10061-10065<br />
were in Duval County. The application includes letters of support from<br />
representatives of the ESHC, the Medical Home <strong>for</strong> Homeless Children<br />
Project, Family Promise of Jacksonville, and the I.M. Sulzbacher Center<br />
<strong>for</strong> the Homeless. The applicant <strong>state</strong>s it is a corporate member of the<br />
Homeless Coalition of Jacksonville, Inc. and has attended regular<br />
monthly membership meetings to stay current with relevant topics<br />
affecting the homeless in the area. United concludes by restating its<br />
condition #3 specific to the homeless which includes a list of the<br />
following shelters: City Rescue Mission, Hubbard House, the Salvation<br />
Army, the Sulzbacher Center, and Trinity Rescue Mission. As noted<br />
above the applicant has a letter of support from the Sulzbacher Center.<br />
Concerning the rural population, the applicant focuses primarily on<br />
Baker County as particularly underserved. Baker County is in the St.<br />
Johns River Rural <strong>Health</strong> Network and is a designated <strong>Health</strong><br />
Professional Shortage Area and Medically Underserved Area by the<br />
Shortage Designation Branch, Bureau of <strong>Health</strong> Professions, <strong>Health</strong><br />
Resources and Services <strong>Administration</strong>, US Department of <strong>Health</strong> and<br />
Human Services. Both these designations are verified by the <strong>Agency</strong> 8 .<br />
Letters of support from this area are included in the application. The<br />
applicant believes its experience is well suited to reach this underserved<br />
rural area indicating that nearly 50 percent of its hospice programs are<br />
located in rural areas of Georgia, South Carolina and North Carolina.<br />
The applicant indicates this includes 11 of UHS‟ 25 programs that are<br />
considered rural by federal guidelines or have been considered rural in<br />
previous years. United indicates that UHS has three other programs that<br />
have service areas that are largely rural but are considered to be part of a<br />
metropolitan statistical area. UHS <strong>state</strong>s that it will use the National<br />
Hospice and Palliative <strong>Care</strong> Organization‟s recommendations <strong>for</strong> rural<br />
hospice care specific to hiring nurses <strong>for</strong> on-call coverage, joint nurse<br />
and social work visits and have a full-time staff position to assist in<br />
promoting hospice services in the area. The applicant conditions its<br />
proposal to the opening of an office in Baker County immediately upon<br />
project approval and an office in Nassau County by the end of its second<br />
year. It also conditions it will become a member of and join the St.<br />
Johns River Rural <strong>Health</strong> Network to address rural hospice concerns.<br />
Concerning patients in need of continuous care, the applicant notes a<br />
<strong>state</strong>wide average of 2.4 percent <strong>for</strong> continuous care days as a percent of<br />
total days in 2008, compared to the Hospice Service Area 4A average of<br />
0.3 percent continuous care days. United indicates that the 2008<br />
Medicare Cost Report and NHA Analysis data shows continuous care<br />
8 http://hpsafind.hrsa.gov/HPSASearch.aspx. The <strong>Agency</strong> notes the Baker County, Florida Primary<br />
<strong>Care</strong> HPSA designation is current and the MUA designation date was November 1, 1978.<br />
45
CON Action Numbers: 10061-10065<br />
accounted <strong>for</strong> 0.3 percent patient days at Community Hospice and Haven<br />
Hospice, and 0.2 percent of Heartland‟s patient days. The applicant<br />
contends that the limited availability of continuous care in Service Area 4<br />
discourages the ability to maintain the patient‟s home as the primary<br />
focus of care. United conditions that 2.5 percent of its total patient days<br />
will be continuous care patient days by the end of year two. Only cobatched<br />
applicant, VITAS <strong>Health</strong>care Corporation of Florida, conditions<br />
<strong>for</strong> a higher percentage of continuous care days by the end of year two (at<br />
3.0 percent).<br />
Concerning non-cancer patients, the applicant <strong>state</strong>s that of the 925<br />
projected „gap‟ in hospice admissions <strong>for</strong> the January 2011 batching<br />
cycle, 82 percent will be non-cancer. The applicant <strong>report</strong>s it has the<br />
most experience and greatest concentration of patients within the noncancer<br />
disease category. United indicates that 73.3 percent of its total<br />
admissions during the 12-month period ending October 31, 2009, were<br />
non-cancer diagnoses. The applicant <strong>state</strong>s that United‟s non-cancer<br />
admissions were as high as 87.5 percent in some programs. The<br />
applicant previously mentioned its <strong>Care</strong>Beyond Program, in which<br />
disease-specific hospice care is applied to applicable patients, depending<br />
on the particular diagnosis.<br />
United provides a brief description of existing hospice programs and<br />
likely impact in the area, if the project is approved. Existing programs<br />
are <strong>state</strong>d to provide care primarily to the Caucasian demographic,<br />
accounting <strong>for</strong> at least some of the African American hospice disparity in<br />
the area. Due to the documented published need, the applicant<br />
anticipates no negative impact upon project approval and the <strong>Agency</strong><br />
notes no letters of opposition were received from any of the existing<br />
hospice programs in Hospice Service Area 4A.<br />
As part of its in-depth marketing field survey and analysis ef<strong>for</strong>ts, the<br />
applicant <strong>state</strong>s that United Hospice conducted a town hall meeting at<br />
the Crown Plaza Hotel in Jacksonville (Duval County), on December 15,<br />
2009. The applicant provides the town hall timely invitation<br />
announcement letter and a signed affidavit that notice of the <strong>for</strong>um was<br />
published in The Florida Times-Union <strong>for</strong> three consecutive days.<br />
Finally, United Hospice provides a discussion of why it should be<br />
approved over the other 4A competitors in this batching cycle.<br />
46
CON Action Number: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) indicates that<br />
based on its analysis of the Medicare Hospice Standard Analytical File<br />
Limited Data Set and the Denominator File <strong>for</strong> CY 2007 (issued by the<br />
Centers <strong>for</strong> Medicare and Medicaid Services) and meetings with local<br />
leaders, the underserved populations in Hospice Service Area 4A are<br />
African-American patients and non-cancer patients 65 years of age and<br />
older. The applicant‟s justification to note these populations as<br />
underserved is briefly described below.<br />
VITAS indicates that its analysis revealed that only 449 of service area<br />
4A‟s African-American Medicare deaths were admitted to the existing<br />
hospices during calendar year 2007. This results in an African-American<br />
admission rate of 43 percent. The applicant indicates that based on the<br />
<strong>state</strong>‟s average hospice penetration rate <strong>for</strong> African-Americans of 51<br />
percent, an additional 79 African American patients should have received<br />
hospice care. VITAS provides a detailed description of its ef<strong>for</strong>ts to<br />
educate and reach into the African-American community. The<br />
application‟s Tab 14 provided additional in<strong>for</strong>mation on VITAS corporate<br />
partnerships and its extensive out-reach programs to African-Americans<br />
and Hispanics.<br />
The applicant provides the following table to support its contention that<br />
VITAS is doing a better job of serving African-Americans than the existing<br />
Service Area 4A providers and Odyssey.<br />
Percentage of Hospice Admissions Who Were African-American in 2007<br />
Selected Florida Counties & Hospice Organizations<br />
Hospice Hospice Percent Resident Percent Percent Difference<br />
Community 12.3% 12.1% 1.7%<br />
Haven 9.5% 11.2% -15.2%<br />
Heartland 5.6% 12.1% -53.7%<br />
Odyssey 6.0% 8.5% -29.4%<br />
VITAS 10.1% 7.1% 42.3%<br />
Source: CON Application #10065, page 51.<br />
Note: Hospice Percent is the percent of the hospice’s patients who were African American.<br />
Resident Percent is percent of all hospice patients in these areas who were African Americans.<br />
As the table above shows, 10.1 percent of VITAS admissions were African<br />
American. African Americans were 7.1 percent of all hospice admissions<br />
in the service area resulting in a 3.0 percent difference. The VITAS<br />
percentage is 42.2 percent higher (10.1 percent/7.1percent) than the<br />
resident percentage. Should the applicant‟s numerous qualifying<br />
<strong>state</strong>ments (See CON #10065, page 51 and Tab 13) to its analysis be<br />
accurate, it appears that VITAS is doing a better job of serving African<br />
Americans than the existing Service Area 4A providers and Odyssey.<br />
47
CON Action Numbers: 10061-10065<br />
VITAS concludes this portion of its need discussion by citing its support<br />
letters from individuals and organizations which indicate that the African<br />
American community in Service Area 4A is underserved and approval of<br />
the applicant will enhance access.<br />
VITAS provided a chart showing 4A Need by Category contained in the<br />
<strong>Agency</strong>‟s hospice need calculation on page 52 of their application. The<br />
applicant compares projected need based on the <strong>state</strong> average to the 4A<br />
service area with the <strong>state</strong> projections by diagnostic category and age (i.e.<br />
Cancer age under 65 and 65 and over and „All Other‟ age under 65 and<br />
65 and over) they conclude that the service area is underserved<br />
especially in the age 65 and over „Other‟ category. The applicant<br />
indicates that with 679 of the projected 925 incremental visits, the „other‟<br />
age 65 and over category is 73.4 percent of the total projected need.<br />
The applicant provides the following table to support its contention that<br />
VITAS is doing a better job of serving non-cancer patients than the<br />
existing Service Area 4A providers and also exceeds the <strong>state</strong> average.<br />
Experience with Non-Cancer Patients<br />
12 Month Periods Ending June 30<br />
2007 2008 2009<br />
Existing 4A Providers 59.22% 59.30% 60.80%<br />
VITAS Florida Hospices 67.31% 66.83% 68.06%<br />
State of Florida 63.02% 64.02% 64.60%<br />
Source: CON Application #10065, page 53.<br />
According to the applicant, <strong>for</strong> the 12-month period ending June 30,<br />
2009, 68.1 percent of VITAS‟ Florida hospice patients had a non-cancer<br />
diagnosis, 12 percent higher than existing Hospice Service Area 4A<br />
hospice providers. The applicant also discussed causes of death in the<br />
hospice service area in years 2006 through 2008 and <strong>state</strong>s that VITAS<br />
will develop programs <strong>for</strong> patients with heart disease, Alzheimer‟s<br />
disease, HIV/AIDS and pulmonary conditions. The applicant references<br />
specialized VITAS programs <strong>for</strong> specific disease categories such as COPD,<br />
Alzheimer‟s, heart disease, HIV/AIDS and diabetes. VITAS also indicates<br />
that in many cases patients age 65 and older with a non-cancer<br />
diagnosis are already in nursing homes when hospice services commence<br />
and that VITAS has already worked with nursing homes in Florida to<br />
address this circumstance. VITAS has the most letters of commitment to<br />
enter into appropriate arrangements <strong>for</strong> inpatient hospice beds, should<br />
the project be approved.<br />
48
2. <strong>Agency</strong> Rule Criteria and Preferences<br />
CON Action Number: 10061-10065<br />
a. Rule 59C-1.0355(4)(e) Florida Administrative Code. Preferences <strong>for</strong><br />
a New Hospice Program. The <strong>Agency</strong> shall give preference to an<br />
applicant meeting one or more of the criteria specified in the below<br />
listed subparagraphs:<br />
(1) Preference shall be given to an applicant who has a<br />
commitment to serve populations with unmet needs.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061)<br />
agrees to serve any and all populations in Hospice Service Area 4A<br />
with unmet hospice needs. The applicant indicates the areas of<br />
highest unmet hospice need in the area are as follow:<br />
• all ages in all diagnostic groups;<br />
• one new hospice office, upon initial operation, by designated zip<br />
code, in the following counties – Duval, Clay and St. Johns (this<br />
is conditioned by the applicant); and<br />
• one dedicated community relations coordinator (this is<br />
conditioned by the applicant) to support and coordinate with<br />
non-health care provider key constituency groups, e.g.,<br />
churches, inner city organizations, support groups, cancer<br />
society, homeless organizations, low income housing, etc.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) <strong>state</strong>s there are<br />
“special and not normal” circumstances that warrant approval of<br />
another hospice program in the area. These “special and not<br />
normal” circumstances are identified by the applicant as follows:<br />
• the consistently underserved patient group – cancer patients 65<br />
years of age and older;<br />
• the consistently underserved patient group – non-cancer<br />
patients 65 years of age and older; and<br />
• the consistently underserved group – non-cancer patients under<br />
age 65.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) <strong>state</strong>s<br />
that no definition exists <strong>for</strong> “unmet needs” but does make reference<br />
to Chapter 59C-1.008(2)(e), Florida Administrative Code 9 . The<br />
applicant notes that cancer patients age 65 and older in the service<br />
9 Chapter 59C-1.008(2)(e)3, “The existence of unmet need will not be based solely on the absence of a<br />
health service, health care facility, or beds in the district, subdistrict, region or proposed service area”.<br />
49
CON Action Numbers: 10061-10065<br />
area <strong>for</strong> the 12-month period ending June 30, 2009 had a 0.3<br />
percent rate of under service compared to the <strong>state</strong>wide average.<br />
For the same period, non-cancer patients age 65 and older in the<br />
service area had a 6.8 percent rate of under service. The applicant<br />
indicates it will serve both the underserved population as well as<br />
categories that were not shown as underserved. The applicant<br />
expects to serve 402 hospice patients in year one and 615 in year<br />
two (CON Application #10063, page #2-4, Table 2-4).<br />
United Hospice of Florida, Inc. (CON #10064) indicates that 82<br />
percent of the unmet need in the hospice service area is in the<br />
non-cancer category and that in several of its programs, 85.2<br />
percent of United Hospice‟s admissions are non-cancer patients.<br />
United <strong>state</strong>s that the following groups are underserved in Hospice<br />
Service Area 4A regarding hospice care:<br />
• the Africa American population;<br />
• the homeless population;<br />
• the rural population;<br />
• patients in need of continuous care; and<br />
• terminally ill non-cancer patients.<br />
The applicant proposes conditions to address the African-<br />
American, homeless and rural populations (particularly Baker and<br />
Nassau Counties and membership in the St. Johns Rural <strong>Health</strong><br />
Network).<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) <strong>state</strong>s<br />
that the greatest unmet need <strong>for</strong> hospice service in the area is<br />
among the following populations:<br />
• African-American population; and<br />
• Non-cancer patients (particularly those age 65 and older).<br />
The applicant notes that 679 of the 925 unmet hospice need in the<br />
area (or about 74 percent of the unmet need) was in terminal noncancer<br />
patients age 65 and older. Also, they estimate 79 African-<br />
Americans in the area had unmet hospice need.<br />
(2) Preference shall be given to an applicant who proposes to<br />
provide the inpatient care component of the hospice program<br />
through contractual arrangements with existing health care<br />
facilities, unless the applicant demonstrates a more costefficient<br />
alternative.<br />
50
CON Action Number: 10061-10065<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) has<br />
two acute care hospital letters of willingness to provide inpatient<br />
beds <strong>for</strong> hospice services – one is from Memorial Hospital-<br />
Jacksonville (Duval County) and one is from Orange Park Medical<br />
Center (Clay County). The applicant <strong>state</strong>s that it will have<br />
contracts in place in each of Hospice Service Area 4A‟s five<br />
counties; however, this is not conditioned by the applicant.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) does not include an<br />
acute care hospital or a skilled nursing facility commitment letter<br />
to enter into an arrangement <strong>for</strong> inpatient beds, though it <strong>state</strong>s it<br />
is in ongoing discussions to obtain memoranda of understanding<br />
<strong>for</strong> general inpatient contracts with potential provider partners in<br />
the service area. To support its history in obtaining such<br />
agreements, the applicant provides sample provider agreements<br />
and a list of Volusia County and Miami-Dade County like contract<br />
agreements (CON Application #10062, Appendix N).<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) has a<br />
letter of willingness to provide inpatient beds <strong>for</strong> hospice services<br />
from Kindred Hospital-North Florida, a long-term care hospital<br />
located in Clay County. The applicant indicates this would<br />
promote access to residents of Clay and St. Johns Counties. The<br />
applicant also proposes to provide inpatient care through<br />
contractual agreements with area hospitals and nursing homes.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s<br />
commitments to enter into contractual agreements <strong>for</strong> inpatient<br />
services are in discussion, pending CON approval with the<br />
following providers: Memorial Hospital-Jacksonville (Duval<br />
County), Kindred Hospital North Florida (Clay County), River<br />
Pointe Behavioral <strong>Health</strong> Center (Duval County), Wekiva Springs<br />
Center <strong>for</strong> Women (Duval County), Life <strong>Care</strong> Center of Orange Park<br />
(Clay County), Quality <strong>Health</strong> of Fernandina Beach (Nassau<br />
County), W. Frank Wells Nursing Center (Baker County), Moultrie<br />
Creek Nursing & Rehabilitation Center (St. Johns County), and<br />
Ponce de Leon <strong>Care</strong> Center (St. Johns County).<br />
The following four facilities make specific reference to entering into<br />
contractual agreements with United <strong>for</strong> inpatient services to<br />
hospice patients, should the applicant be approved: River Point<br />
Behavioral <strong>Health</strong> Center and Wekiva Springs Center <strong>for</strong> Women<br />
(Duval County inpatient psychiatric hospitals) and two nursing<br />
homes, Life <strong>Care</strong> Center of Orange Park (Clay County) and Quality<br />
51
CON Action Numbers: 10061-10065<br />
<strong>Health</strong> of Fernandina Beach (Nassau County). Memorial Hospital-<br />
Jacksonville <strong>state</strong>s that they would be willing to enter into an<br />
agreement with United Hospice should they begin delivering<br />
services here and would be very interested in partnering with<br />
United to enhance the health care of local residents. Kindred<br />
Hospital North Florida and W. Frank Wells Nursing Center <strong>state</strong><br />
that they would be “willing to partner with” or “work cooperatively<br />
with” United to provide inpatient hospice care. The support letters<br />
from Moultrie Creek Nursing & Rehabilitation Center and Ponce de<br />
Leon <strong>Care</strong> Center <strong>state</strong> they are willing to “use them (United) to<br />
provide inpatient care to our residents”.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) has six<br />
letters of support that <strong>state</strong> willingness to enter into an inpatient<br />
arrangement in providing inpatient beds <strong>for</strong> hospice services. They<br />
are all SNF providers, two being in Clay County (The Terrace at<br />
Fleming Island and Governor‟s Creek <strong>Health</strong> and Rehabilitation<br />
Center) and the remaining four being located in Duval County<br />
(Fleet Landing, Harts Harbor <strong>Health</strong> <strong>Care</strong> Center, San Jose <strong>Health</strong><br />
and Rehabilitation Center and West Jacksonville <strong>Health</strong> and<br />
Rehabilitation Center). Fleet Landing and The Terrace at Fleming<br />
Island indicate that they would be willing to consider entering into<br />
an inpatient agreement with VITAS. None of the nursing homes<br />
indicate a specific number of beds they would be willing to contract<br />
out to VITAS.<br />
(3) Preference shall be given to an applicant who has a<br />
commitment to serve patients who do not have primary<br />
caregivers at home; the homeless; and patients with AIDS.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061)<br />
<strong>state</strong>s that they are committed to serving patients who do not have<br />
primary caregivers at home, the homeless, and patients with AIDS.<br />
The applicant <strong>state</strong>s that as of December 15, 2009, 7.7 percent of<br />
the patients it served lived alone and 2.9 percent lived with a<br />
“compromised caregiver”. The applicant indicates that it does not<br />
require that a patient have a caregiver in the home to be part of<br />
their program. In addition, the applicant <strong>state</strong>s it has provided<br />
care to individuals in boarding homes, homeless shelters,<br />
psychiatric centers, and correctional facilities. The applicant<br />
<strong>state</strong>s that it serves all patients and, in addition to those who live<br />
alone, this includes transients, and those who have AIDS, or are<br />
homeless. The applicant <strong>state</strong>s that if a homeless patient desiring<br />
Compassionate <strong>Care</strong> Hospice care is discharged from a hospital<br />
52
CON Action Number: 10061-10065<br />
and has nowhere to go, Compassionate <strong>Care</strong> will place them in an<br />
inpatient unit and apply <strong>for</strong> Medicaid. Once the patient qualifies<br />
and receives Medicaid, they will be placed into a long-term care<br />
environment in which hospice care can still be provided as long as<br />
the patient requires such care.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) <strong>state</strong>s that it<br />
accepts all patients who meet admission criteria, including<br />
patients who do not have a primary care giver at home, as well as<br />
the homeless and patients with AIDS. The applicant explains that<br />
an Odyssey nurse will coordinate appropriate <strong>action</strong> and<br />
placement with the rest of the interdisciplinary team and hospice<br />
physician or attending physician. Odyssey describes numerous<br />
mechanisms to address admissions and placement (CON<br />
Application #10062, page #83 and Appendix F - Policies &<br />
Procedures Matrix).<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) includes,<br />
as part of its admission policy 10 , that Seasons does not require a<br />
patient to have a primary caregiver. In the absence of a caregiver,<br />
the applicant <strong>state</strong>s it begins discussion upon admission with the<br />
patient to make plans <strong>for</strong> his/her care when he/she is no longer<br />
able to make decisions. Seasons also <strong>state</strong>s that as part of this<br />
policy, admission is limited to those patients who have a family<br />
member or designated person who is able and willing to assume<br />
the role of caregiver. The applicant <strong>state</strong>s it will treat persons with<br />
AIDS and that Hospice Service Area 4A has a higher average AIDS<br />
rate (26.1 percent) and AIDS death rate (9.8 percent) than the <strong>state</strong><br />
average AIDS rate (23.7 percent) and <strong>state</strong>wide death rate (8.4<br />
percent) <strong>for</strong> the three-year period ending 2008 [CON Application<br />
#10063, page #2-8, Table 2-5].<br />
United Hospice of Florida, Inc. (CON #10064) commits to<br />
serving those who do not have a primary caregiver, the homeless<br />
and those with AIDS. United, more than any other co-batched<br />
applicant, provides substantial letters of support from<br />
organizations that serve the homeless and conditions their<br />
application to serve selected homeless shelter facilities and<br />
10 CON Application #10063, page #2-6, Policy #7.<br />
53
CON Action Numbers: 10061-10065<br />
organizations. The applicant <strong>state</strong>s it will request a caregiver upon<br />
admission and if a caregiver is not identified, they will develop, as<br />
part of the plan of care, a means by which daily care and safety<br />
needs of the patient will be met. It is further <strong>state</strong>d the applicant<br />
will seek to assist in developing a caregiver network. If a caregiver<br />
arrangement cannot be established in the least restrictive<br />
environment practical, the applicant <strong>report</strong>s it may recommend<br />
placement in an ALF or SNF, in which residential care would be<br />
available. The applicant also <strong>state</strong>s it is aware of the higher AIDS<br />
rate in the hospice service area, indicating that some of those that<br />
are homeless are AIDS patients. The applicant indicates that <strong>for</strong><br />
the 12-month period ending October 31, 2009, 1.2 percent of all<br />
United Hospice admissions were AIDS related patients.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) <strong>state</strong>s<br />
that if a patient lives alone and a caregiver is not nearby and able<br />
to care <strong>for</strong> the patient, VITAS will assist the patient in developing<br />
an applicable network. VITAS will also recommend qualified adult<br />
sitter services, if applicable and provided a financial hardship is<br />
not created. A 24/7 phone service is <strong>state</strong>d as an option <strong>for</strong> those<br />
who do not have such service. According to the applicant, nursing<br />
home and ALF options will be considered <strong>for</strong> the homeless. VITAS<br />
also indicates an awareness of AIDS patients and HIV related<br />
deaths in the area, with 106 AIDS related deaths in 2006 and 111<br />
such deaths in 2008 in Hospice Service Area 4A. If approved, the<br />
applicant indicates VITAS will institute a program to assure<br />
terminally ill patients with HIV have access to hospice care.<br />
(4) In the case of proposals <strong>for</strong> a hospice service area comprised<br />
of three or more counties; preference shall be given to an<br />
applicant who has a commitment to establish a physical<br />
presence in an underserved county or counties.<br />
Hospice Service Area 4A consists of five counties (Baker, Clay,<br />
Duval, Nassau and St. Johns. There<strong>for</strong>e, this criterion is<br />
applicable. The chart below indicates the number of operational<br />
hospice locations in the service area, by county.<br />
54
CON Action Number: 10061-10065<br />
Hospice Service Area 4A<br />
Operational Hospice Office Locations<br />
By Provider and County as of January 11, 2010<br />
Community Hospice<br />
of Northeast<br />
Florida, Inc.<br />
55<br />
Heartland Home<br />
<strong>Health</strong> <strong>Care</strong> and<br />
Hospice<br />
County/Provider<br />
Haven<br />
Hospice*<br />
Baker 0 0 0 0<br />
Clay 0 0 0 0<br />
Duval 1 1 1 3<br />
Nassau 1 0 0 1<br />
St. Johns 1 1 0 2<br />
Total 3 2 1 6<br />
Source: <strong>Agency</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong> <strong>Administration</strong> Home <strong>Care</strong> Unit Licensure Records.<br />
*Haven Hospice‟s main office is in Alachua County. Community Hospice deleted its Clay office<br />
effective 8/1/09 and has three inpatient hospice facilities in Duval County.<br />
Total<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) is<br />
the only co-batched applicant to condition, by zip code, <strong>for</strong> three<br />
office locations in the hospice service area upon commencement of<br />
services. Those counties are as follows: Clay, Duval and St. Johns.<br />
The applicant also <strong>state</strong>s that if demand requires an office in<br />
Nassau County and/or Baker County, an office will be opened in<br />
either or both counties; however, this is not conditioned.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) conditions <strong>for</strong> the<br />
immediate development of a main office in Duval County and two<br />
satellite offices – one in Clay County by the end of year one and<br />
one in Nassau County by the end of year two.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
conditions to locate a main office in Clay County. This applicant<br />
contends that Clay County offers the best location <strong>for</strong> an office<br />
based on in-hospital death rates in the service area. The applicant<br />
notes that Baker, Clay and Duval Counties have higher in-hospital<br />
death rates among the 65 years of age and older population, per<br />
1,000 residents in calendar year 2008 (CON Application #10063,<br />
page #2-9, Table 2-6). Though the applicant notes that the higher<br />
death rate in this population is in Baker County (at 13.5 percent<br />
<strong>for</strong> elderly residents per 1,000 population in calendar year 2008),<br />
the relatively low mortality count and the county‟s location<br />
(tangent to the western border of Duval County) rules Baker<br />
County out as a “good location” from which to serve the area.<br />
Seasons finds that Duval County is well represented concerning<br />
office locations, considering existing hospices in the area. Seasons<br />
also considers, in selecting Clay County <strong>for</strong> an office location, that<br />
after ruling out Baker County and Duval County, among the<br />
remaining three counties, Clay County residents have similar
CON Action Numbers: 10061-10065<br />
death rates among like diseases in both Nassau and St. Johns<br />
Counties (CON Application #10063, page #2-10, Table 2-7). Again,<br />
the applicant finds Clay County is indicated <strong>for</strong> an office location<br />
and believes access to the remaining four counties can occur.<br />
United Hospice of Florida, Inc. (CON #10064) notes that<br />
utilizing the <strong>Agency</strong>‟s population estimates and projections<br />
publication (dated September 2009) Baker County‟s population<br />
represents only 2.0 percent of Hospice Service Area 4A and only<br />
2.2 percent of the deaths in the hospice area. However, the<br />
applicant also notes that none of the existing hospices have an<br />
office located in Baker County and contends that Baker County<br />
residents lack accessible hospice services. The applicant<br />
conditions that it will open a main office in the City of Jacksonville<br />
(Duval County) and two satellite offices – one in Baker County<br />
immediately upon licensure and a second one in Nassau County by<br />
the end of their second year of operation.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) <strong>state</strong>s it<br />
conditions to have satellite offices in Baker and Nassau Counties<br />
during the first year of operation. It also <strong>state</strong>s on page 17 of the<br />
application that it conditions to establish a main office in Duval<br />
County.<br />
(5) Preference shall be given to an applicant who proposes to<br />
provide services that are not specifically covered by private<br />
insurance, Medicaid, or Medicare.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061)<br />
<strong>state</strong>s it currently provides services that are not covered by private<br />
insurance, Medicaid, or Medicare, and will continue to do so in the<br />
program proposed <strong>for</strong> Hospice Service Area 4A. Compassionate<br />
<strong>Care</strong> <strong>state</strong>s it provides services needed to all patients regardless of<br />
payer status, and in many instances regardless of legal status.<br />
Compassionate <strong>Care</strong> <strong>state</strong>s that in its most recent year (exact year<br />
is not <strong>state</strong>d) the proportion of care delivered to patients who were<br />
unable to pay was 2.6 percent.<br />
In addition to providing its full-range of services to patients not<br />
covered by private insurance, Medicaid or Medicare, the applicant<br />
<strong>state</strong>s it offers services that are not included in the range of<br />
services typically reimbursed by these programs. These services<br />
include:<br />
56
CON Action Number: 10061-10065<br />
Bereavement – Bereavement counselors are <strong>state</strong>d to assist<br />
grieving families in finding healthy paths to healing. These<br />
counselors are said to be available to family members <strong>for</strong> up to<br />
15 months following the death of the hospice patient and<br />
volunteers are said to be trained to understand healthy<br />
bereavement care, to recognize abnormal patterns of grief, and<br />
to provide appropriate support and encouragement through the<br />
grieving process. Compassionate <strong>Care</strong> also proposes that it will<br />
provide age-specific grief group counseling, through programs<br />
such as the Rainbow Program, a pediatric bereavement<br />
program, as well as individualized one-on-one counseling. The<br />
applicant provides its bereavement policy <strong>for</strong> <strong>Agency</strong> review<br />
(CON Application #10061, Appendix Q-Bereavement<br />
Services/Policy No. 2003.7).<br />
• Cardiac Connection Program – This program is designed <strong>for</strong><br />
those with end-stage heart failure and advanced congestive<br />
heart failure, which may include continuous care (CON<br />
Application #10061, Appendix B and Appendix R).<br />
• Promise Program – Promise is an acronym <strong>for</strong> “Providing Renal<br />
Options: More Individualized Support and Education”.<br />
Specifics are provided by the applicant (CON Application<br />
#10061, Appendix B).<br />
• Compassionate <strong>Care</strong> Hospice Foundation Activities –<br />
Compassionate <strong>Care</strong> Hospice Foundation, Inc. is <strong>state</strong>d to be a<br />
non-profit fundraising organization affiliated with<br />
Compassionate <strong>Care</strong> Hospice which provides financial<br />
assistance to terminally ill patients and families in need. It also<br />
is <strong>state</strong>d to support public programs that provide the general<br />
public with in<strong>for</strong>mation regarding end-of-life choices allowing<br />
individuals to determine and communicate their wishes and<br />
help their families prepare <strong>for</strong> the future. The applicant<br />
conditions that the Compassionate <strong>Care</strong> Hospice Foundation<br />
will provide assistance to needy patients and families. The<br />
following are <strong>state</strong>d examples of instances in which the<br />
Compassionate <strong>Care</strong> Hospice Foundation provided assistance to<br />
patients and families:<br />
o Rent, mortgage and utility payments are made <strong>for</strong><br />
individuals and families;<br />
o Summer camp <strong>for</strong> an 11 year-old child whose single mother<br />
was terminally ill,<br />
57
CON Action Numbers: 10061-10065<br />
o A special therapeutic pillow to help ease pain <strong>for</strong> a terminally<br />
ill child,<br />
o Covering the cost of dinner and a babysitter <strong>for</strong> parents who<br />
were caring <strong>for</strong> a terminally ill child and had not had any<br />
time together “in a very long while”,<br />
o Funding special projects, volunteer ef<strong>for</strong>ts, and educational<br />
programs in various communities designed to raise public<br />
awareness about hospice care; and<br />
o Providing an annual $10,000 grant toward funding<br />
Compassionate Courage, a program <strong>for</strong> school-aged children<br />
with a family member undergoing cancer treatments,<br />
terminal illness, or children who have experienced a loss due<br />
to death or changes in family structure.<br />
• Compassionate Courage – A program offering a safe place <strong>for</strong><br />
children to express their feelings and share with others who<br />
have experienced similar loss. Compassionate Courage<br />
programs provide bereavement support groups <strong>for</strong> elementary<br />
and middle school children who are dealing with a significant<br />
loss.<br />
• Complementary Therapies – Complementary therapies are<br />
<strong>state</strong>d to be offered at no charge to hospice patients to ease pain<br />
and discom<strong>for</strong>t. Sample therapies include the following:<br />
o Songs <strong>for</strong> the Soul – Music therapists provide unique,<br />
relaxing music to alleviate stress, pain and discom<strong>for</strong>t, and<br />
to promote peace, tranquility, and relaxation.<br />
o Looking Great – A licensed beautician provides haircuts,<br />
hairstyling, and beauty tips, helping patients look and feel<br />
their best.<br />
o Therapeutic Touch – A licensed massage therapist provides a<br />
variety of massage techniques to reduce stress, relieve<br />
cramps, and improve circulation promoting com<strong>for</strong>t and an<br />
increased sense of well being.<br />
o Pet Visitor Program – Physical contact with pets has been<br />
shown to have a number of benefits, reducing stress and<br />
increasing joy and well being. To date, Compassionate <strong>Care</strong><br />
has incorporated dogs, cats and rabbits in its program, to<br />
the delight of many patients.<br />
o Good Scents – An aroma therapy program.<br />
o Art Therapy – A program assisting patient and family<br />
members in creating arts and crafts projects. Using ones<br />
hands to create a product helps alleviate depression and<br />
provides a sense of connectedness and accomplishment.<br />
58
CON Action Number: 10061-10065<br />
• Rainbow Program – This program provides support <strong>for</strong> children<br />
who are experiencing grief through a death or divorce in the family,<br />
designed to bring hope to grieving children, moving through hurt<br />
into healing and hope (CON Application #10061, Appendix I-<br />
Compassionate <strong>Care</strong> 4 Kids Materials/Pediatrics Program).<br />
• Com<strong>for</strong>t Corners – This is physical areas in long-term care facilities<br />
where a warm, home-like environment is provided <strong>for</strong> patients and<br />
their families.<br />
The applicant assures that discriminatory factors (such as race,<br />
ethnicity, gender, age, religious affiliation, diagnosis, financial and<br />
insurance status and any other factors that would have the effect<br />
of discriminating) will not be applied. This is conditioned. As<br />
<strong>state</strong>d previously, hospice programs are required by federal and<br />
<strong>state</strong> law to provide services to everyone requesting them and<br />
there<strong>for</strong>e the <strong>Agency</strong> would not place conditions on a program to<br />
provide legally required services such as palliative radiation and<br />
chemotherapy and those lacking the ability to pay.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) <strong>state</strong>s that services<br />
not specifically covered by Medicaid or Medicare will be provided<br />
and include the following: pet, music, massage and aroma<br />
therapies; dialysis and palliative radiation and palliative<br />
chemotherapy. With the exception of dialysis, these non-covered<br />
services are conditioned by the applicant. It is further <strong>state</strong>d the<br />
hospice services will be provided to all patients regardless of their<br />
ability to pay and this too is conditioned. As <strong>state</strong>d previously,<br />
hospice programs are required by federal and <strong>state</strong> law to provide<br />
services to everyone requesting them and there<strong>for</strong>e the <strong>Agency</strong><br />
would not place conditions on a program to provide legally required<br />
services such as palliative radiation and chemotherapy and those<br />
lacking the ability to pay.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) provides<br />
the following services not specifically covered by payers.<br />
• Music Therapy – every new program has a full time music<br />
therapist and more is added as the program grows to a census<br />
ratio of one music therapist to 75 enrollees.<br />
Seasons <strong>state</strong>s that even when a person is no longer conscious<br />
or speaking, they can be consoled and com<strong>for</strong>ted with music.<br />
59
11 http://www.joycesimard.com/.<br />
CON Action Numbers: 10061-10065<br />
The applicant conditions that music therapy will be a standard<br />
core service, as prescribed in the plan of care. Some, but not all<br />
the planned <strong>for</strong> music therapy goals are as follows:<br />
reminiscence (focus on assets and positive experiences);<br />
identification and expression of emotions; increased<br />
socialization; establishment of trust and rapport; development<br />
of effective coping skills; mood management; a medium <strong>for</strong><br />
closure and many others.<br />
• Pet Therapy – a specialized program within volunteer services<br />
that provides specialized training <strong>for</strong> volunteers with pets that<br />
are therapy certified. Seasons notes pet therapy will be<br />
included in the plan of care. The volunteer coordinator oversees<br />
the pet therapy program.<br />
• Palliative <strong>Care</strong> Program – Seasons <strong>state</strong>s this program provides<br />
clinical support management <strong>for</strong> people living with an advanced<br />
illness and emotional support <strong>for</strong> their families and caregivers.<br />
The program covers all ages and is <strong>state</strong>d to be different from<br />
hospice in the following five ways: the program is applied earlier<br />
in the disease process than hospice; it does not require a sixmonth<br />
prognosis; it can be utilized with traditional curative<br />
care; it can be accessed while the patient is undergoing<br />
rehabilitation at a skilled nursing facility; it provides physician<br />
and nurse practitioner consultations whereas hospice includes<br />
an array of services such as 24-hour support from the<br />
interdisciplinary hospice care team, as well as durable<br />
equipment.<br />
• Touch of All Seasons – a comprehensive program designed <strong>for</strong><br />
patients with advanced dementia and other neurological<br />
illnesses, <strong>state</strong>d to have been developed by Joyce Simard, MSW,<br />
an internationally recognized dementia expert 11 . Goals of this<br />
program are, in summary, to overall reduce pain and suffering,<br />
maintain dignity and support the family. Benefits to this<br />
program are, in summary, to overall have a person centered<br />
care approach <strong>for</strong> this population, enhance com<strong>for</strong>t, create<br />
calm, teach loved ones how to interact and add a layer of<br />
professional caregivers to the existing team.<br />
• Open Access – Seasons <strong>state</strong>s experience with hospice care<br />
where the patient suffers complications or multiple system<br />
involvement in addition to the terminal diagnosis and provides<br />
60
CON Action Number: 10061-10065<br />
services such as ventilator-at-home care, radiation therapy and<br />
chemotherapy. These three services are specifically<br />
conditioned. The applicant notes some services that may apply<br />
in a multiple system involvement patient are as follows: IV<br />
antibiotics, TPN, IV hydration, cardiac drips, chest tubes, tube<br />
feedings, hemo/peritoneal dialysis <strong>for</strong> co-occurring diagnosis,<br />
palliative radiation, oral chemotherapy, biological response<br />
modifiers (such as Procrit, Neupogen, Epogen), patients needing<br />
additional time to complete the discharge planning from the<br />
acute care setting, and patients who must finish a course of<br />
treatment. Seasons identifies the following seven benefits to the<br />
Open Access Program:<br />
• increases the time <strong>for</strong> patients and families to engage in<br />
advance care planning and process issues related to the<br />
advanced illness while utilizing hospice care services;<br />
• allows patients to receive hospice care services earlier and<br />
provides them with more assistance in care planning;<br />
• supports collaborative ef<strong>for</strong>t between the hospice team and<br />
the hospital or other discharge planning team during<br />
difficult communications with patients and their families;<br />
• begins hospice services while the patients are transitioning<br />
from curative care to palliative care;<br />
• helps patients and families understand when care is futile<br />
and allows them to request discontinuation of measures on<br />
their own schedule;<br />
• demonstrates significant length of stay reduction in the<br />
acute care setting and;<br />
• incorporates the referring physician's recommendations into<br />
coordinated plan of care with the patient and family.<br />
• Education – is <strong>state</strong>d to be of the highest caliber available, with<br />
external/community education so that required CEUs can be<br />
acquired to maintain licensure and certifications. Seasons<br />
<strong>state</strong>s it works with Boards of Nursing to become a provider of<br />
continuing education.<br />
61
CON Action Numbers: 10061-10065<br />
• Kangaroo Kids – a summer support camp <strong>for</strong> bereaved children<br />
to include a weekend trip with parent/guardian to one of<br />
Florida‟s theme parks. The applicant indicates this is a<br />
specialized program and is conditioned 12 . According to the<br />
applicant, Kangaroo Kids is a program with a total medical,<br />
spiritual, emotional, physical, and social approach that focuses<br />
on caring <strong>for</strong> the patient's entire family: parents, siblings, and<br />
grandparents. Kangaroo Kids is described as a unique pediatric<br />
program dedicated to offering all-encompassing care to children<br />
who are suffering life-threatening illnesses and/or death. It is<br />
based on the belief that these children can thrive best when<br />
their families are encouraged to care <strong>for</strong> their child at home,<br />
with resources and support from hospice. Seasons <strong>state</strong>s that<br />
goals of the program are as follows: to enhance the quality of life<br />
<strong>for</strong> children and their families, to relieve suffering; to control<br />
symptoms, to enable children to stay at home with their<br />
families, to provide caring expertise and support, letting families<br />
know they are not alone and have a shoulder to lean on; to<br />
encourage children to retain their independence and a sense of<br />
being respected <strong>for</strong> who they are and to help family members<br />
move through their emotions and resolve spiritual questions.<br />
According to Seasons, the types of medical conditions seen in<br />
the program include the following: neurodegenerative disorders,<br />
severe metabolic or genetic diseases, end-stage cancers, AIDS,<br />
severe neuromuscular diseases, inoperable cardiac defects,<br />
severe congenital anomalies, and severe multi-system disorders.<br />
• Volunteer Vigil Program – these are direct care volunteers who<br />
have completed all core volunteer requirements, six months<br />
active patient care, express Vigil interest and are available to be<br />
called to service within their defined area of service at a<br />
minimum of two-hour shifts on a regular basis.<br />
• Call Center – a Seasons operated call center <strong>for</strong> afterhours<br />
triage of calls with Seasons employees who are specially trained<br />
in hospice and palliative care and have access to all patients' up<br />
to date patient in<strong>for</strong>mation. Stated to be a fully electronically<br />
integrated system with electronic medical records and other<br />
communication devices used by employees, it is tied-in with<br />
12 CON Application #10063, page #2-17. The <strong>Agency</strong> notes that while the Kangaroo Kids and Kangaroo<br />
Camp programs are conditioned, the applicant does not condition specifically that the program will<br />
include a weekend trip to one of Florida‟s theme parks.<br />
62
CON Action Number: 10061-10065<br />
“HomeWorks” (a <strong>state</strong>d telehealth and patient data collection<br />
and analysis system). Seasons indicates it will be fully<br />
integrated into the national system, allowing support and<br />
tracking, with on-line assistance to staff, who in-turn can<br />
respond more timely, 24 hours a day, seven days a week. This<br />
is conditioned by the applicant.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s that all<br />
patients eligible <strong>for</strong> hospice care will be accepted that are not<br />
covered by private insurance, Medicaid or Medicare. As evidence of<br />
United‟s commitment to serve all those that seek care, the<br />
applicant indicates that in its fiscal year 2009, it provided more<br />
than $223,000 in unfunded care. The applicant re<strong>state</strong>s its<br />
conditions as non-core services. They are repeated here.<br />
1. UHS Home and Community Based Services Provider: Upon<br />
CON approval, United Hospice's ultimate parent, UHS, will<br />
develop, in conjunction with United Hospice, UHS' family of<br />
services and companies in Subdistrict 4A and will enhance<br />
the hospice services available to area residents by making<br />
such services available not only to United's hospice patients,<br />
but also to any other existing hospice provider who wishes to<br />
contract <strong>for</strong> such services. The United Hospice family of<br />
services and companies include United Home <strong>Care</strong>, United<br />
Medical, United Pharmacy Services and United Clinical<br />
Services. This will be measured by a signed declaratory<br />
<strong>state</strong>ment submitted by United Hospice to the <strong>Agency</strong>.<br />
2. African American Outreach: Reflective of its commitment to<br />
enhancing access to the end-of-life care of African American<br />
residents in Subdistrict 4A, the applicant has conditioned<br />
approval of its application on the provision it will implement<br />
and maintain an African American Outreach Program.<br />
• A staff member will be responsible <strong>for</strong> the outreach<br />
initiatives. This individual's objective will be to coordinate<br />
staff activities, plan events and serve as a key contact<br />
within community leaders.<br />
• United Hospice will <strong>for</strong>m a planning and outreach team<br />
consisting of staff, volunteers and community members.<br />
This team will provide support <strong>for</strong> the staff person<br />
assigned primary responsibility <strong>for</strong> outreach ef<strong>for</strong>t.<br />
• United Hospice will host listening sessions with African<br />
American leaders, African American clergy and other<br />
members of the African American community to develop<br />
63
CON Action Numbers: 10061-10065<br />
an understanding of attitudes and beliefs regarding endof-life<br />
care. Some of these organizations will include but<br />
are not limited to:<br />
• Local NAACP branches<br />
• Jacksonville Urban League<br />
• Black Chamber of Commerce<br />
• Jacksonville city Mayor's office<br />
• State Representative Mia Jones<br />
• State Senator Tony Hill Sr.<br />
• State Representative Audrey Gibson<br />
• Other City and County Leaders<br />
• Churches and other religious affiliated groups<br />
• Based on listening sessions, United Hospice will develop a<br />
message, presentation and marketing materials that<br />
address needs and issues expressed by focus group<br />
respondents and the community.<br />
• United Hospice will continually assess existing tools and<br />
obtain or develop new resources as needed to provide<br />
culturally meaningful and appropriate educational<br />
opportunities <strong>for</strong> the African American community.<br />
• The applicant will provide ongoing comprehensive<br />
training <strong>for</strong> staff and volunteers who are actively involved<br />
in the outreach program. These individuals will plan<br />
quarterly town hall meetings with members of the<br />
community to engage, educate and energize individuals to<br />
begin end-of-life conversations in their organizations,<br />
congregations and so <strong>for</strong>th.<br />
• United Hospice will develop and maintain a calendar of<br />
events that address, support and celebrate African<br />
American issues, heritage and healthcare concerns. Staff<br />
members will attend various calendar events with the goal<br />
of making United Hospice of Florida the name and face<br />
known throughout the community.<br />
• The applicant will develop a census tracking tool to<br />
routinely track referrals generated by the outreach<br />
program to measure its ongoing success.<br />
• The applicant will <strong>report</strong> its admissions annually by race,<br />
to measure success and increase in percentage of African<br />
American admissions.<br />
This condition will be measured by a signed affidavit submitted to the<br />
<strong>Agency</strong>.<br />
64
CON Action Number: 10061-10065<br />
3. Homeless Outreach: If awarded a certificate of need <strong>for</strong> the<br />
proposed project, United Hospice will partner with the ESHC to<br />
provide hospice services to Subdistrict 4A homeless individuals in<br />
either a residential or homeless shelter setting coordinated by<br />
ESHC. Specifically, United Hospice will accept the following<br />
conditions on its CON:<br />
• Continue active membership in the ESHC through attendance<br />
at monthly meetings and collaborating with coalition members<br />
in providing services to the homeless population.<br />
• Provide hospice services to homeless population in shelters and<br />
assist with facility placement as appropriate. Shelters may<br />
include but are not limited to City Rescue Mission, Hubbard<br />
House, the Salvation Army, the Sulzbacher Center and Trinity<br />
Rescue Mission.<br />
• United Hospice will provide health screenings at by a registered<br />
nurse once a month at one of the local not-<strong>for</strong>-profit social<br />
service organizations to be determined in collaboration with the<br />
ESHC.<br />
4. Rural Areas Outreach: United Hospice has conditioned this<br />
application on the provision it will open a main office in<br />
Jacksonville plus two satellite offices in rural areas of Subdistrict<br />
4A as follows:<br />
• A Baker County office will open immediately upon licensure to<br />
serve the terminally-ill needs of Baker County residents.<br />
• A Nassau County office will open by the end of United Hospice's<br />
second year of operation.<br />
• Both the Baker and Nassau County offices will be centrally<br />
located to the population and will have a dedicated<br />
interdisciplinary team.<br />
• United Hospice will become a member of and will partner with<br />
the St. Johns Rural <strong>Health</strong> Network to improve the health of the<br />
communities in which United Hospice serves.<br />
5. Patients in Need of Continuous <strong>Care</strong>: United Hospice has<br />
conditioned this application on the provision it will provide, at a<br />
minimum, 2.5 percent of its patient days by the end of year two to<br />
continuous care which exceeds the <strong>state</strong> average, to the extent in<br />
which there is patient demand as determined by the<br />
interdisciplinary team. This condition will be measured via a<br />
signed declaratory <strong>state</strong>ment by United Hospice which may be<br />
supported via review of patient day <strong>report</strong>s by type and month<br />
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CON Action Numbers: 10061-10065<br />
produced by the applicant. United Hospice will monitor and<br />
annually <strong>report</strong> to the <strong>Agency</strong>, overall Subdistrict 4A continuous<br />
care percentage of patient days to determine success of its<br />
continuous care initiative.<br />
6. CHAP Accreditation: United Hospice has conditioned approval of<br />
this application on the provision it will seek and obtain CHAP<br />
accreditation upon certification. This will be measured by<br />
submitting United Hospice's accreditation certificate to the <strong>Agency</strong><br />
upon receipt.<br />
7. Membership Organizations: Upon licensure, United Hospice will<br />
become a member of the following community organizations:<br />
• Florida Hospice and Palliative <strong>Care</strong>;<br />
• Jacksonville Regional Chamber of Commerce;<br />
• St. Johns County Chamber of Commerce;<br />
• Greater Nassau County Chamber of Commerce;<br />
• Clay County Chamber of Commerce; and<br />
• Baker County Chamber of Commerce.<br />
8. United Hospice Foundation: United Hospice Foundation will make<br />
available to Florida residents, its annual scholarship program<br />
targeted at those who are studying nursing, pharmacy or therapy<br />
with an interest in end-of-life care. The scholarship is available<br />
each year to four students in the amount of $2,000 <strong>for</strong> the school<br />
year.<br />
9. Staffing Ratios and Qualification: United Hospice will meet or<br />
exceed all NHPCO Guidelines <strong>for</strong> qualifications and staffing ratios<br />
<strong>for</strong> patient care staff.<br />
10. Pain Reduction: United Hospice will implement rapid pain<br />
management protocols to ensure that 75 percent of patients who<br />
<strong>report</strong> severe pain on a 0-10 scale will <strong>report</strong> a reduction to five or<br />
less by the end of the second day of care on the hospice program.<br />
This condition substantially exceeds the requirements of section<br />
400.60501, Florida Statutes. For patients that do not meet this<br />
pain reduction goal, such patient's plan of care will be evaluated<br />
within 48 hours by the medical director and a Pharm D.<br />
consultant to ensure that appropriate pain reduction measures are<br />
immediately implemented.<br />
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CON Action Number: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) <strong>state</strong>s that all<br />
patients eligible <strong>for</strong> hospice care will be accepted that are not covered by<br />
private insurance, Medicaid or Medicare. As evidence of VITAS‟<br />
commitment to serve all those that seek care, the applicant indicates<br />
that in fiscal year 2008, it provided in excess of $1.9 million in charity<br />
care. The applicant re<strong>state</strong>s its conditions as non-core services. They<br />
are repeated here.<br />
1. The first population subgroup is defined as hospice patients in<br />
need of continuous care: VITAS will provide at least three percent<br />
of its total patient days to continuous care by the end of year two.<br />
2. The second population subgroup is defined as hospice patients<br />
with diagnosis other than cancer. VITAS will guarantee that at<br />
least 65 percent of patients admitted have non-cancer diagnoses.<br />
3. Special Programs: VITAS has conditioned the application on the<br />
provision it will meet or exceed the following quality and patient<br />
satisf<strong>action</strong> indicators:<br />
• Pain Control: On the first day of hospice care responsive<br />
patients will be asked to rate their pain on the 0-10 World<br />
<strong>Health</strong> Organization pain scale (severe pain to worst pain<br />
imaginable). A pain history will be created <strong>for</strong> each patient.<br />
These measures will be recorded in VITAS's proprietary<br />
in<strong>for</strong>mation management system, VITAS Exchange (or Wx") via<br />
a telephone call using the telephone keypad <strong>for</strong> data entry.<br />
These outcome measures will include greater than 70 percent of<br />
patients who <strong>report</strong> severe pain on a seven-10 scale will <strong>report</strong> a<br />
reduction to five or less within 48 hours. Florida Statutes<br />
400.60501 requires only a 50 percent reduction in 96 hours;<br />
this commitment set <strong>for</strong>th by VITAS far exceeds Florida<br />
statutory requirements and is a significant commitment to<br />
quality care.<br />
• Death Attendance: VITAS will attend at least 90 percent of all<br />
deaths to ensure patients do not die alone. This will be<br />
measured via a signed declaratory <strong>state</strong>ment by VITAS which<br />
may be supported via review of patient medical records.<br />
• Patient Family Satisf<strong>action</strong>: VITAS will achieve an overall<br />
patient satisf<strong>action</strong> score of 90 percent or above on patient's<br />
family evaluation of care while under the care of VITAS. This is<br />
determined by a mail-in survey sent by VITAS to the patient's<br />
family and measured by recording all scores.<br />
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CON Action Numbers: 10061-10065<br />
• Discipline Specific Satisf<strong>action</strong>: VITAS will achieve an overall<br />
registered nurse satisf<strong>action</strong> score of 90 percent or above on<br />
patient's family satisf<strong>action</strong> with the VITAS nurse while under<br />
the care of VITAS. This is determined by a mail-in survey sent<br />
by VITAS to the patient's family and measured by recording all<br />
scores.<br />
• Pet Therapy: Implementation of a pet therapy program to begin<br />
immediately. PetPals is a program where screened dogs visit<br />
shut-ins, nursing homes, assisted living facilities adult day care<br />
center and Alzheimer patients. This program offers a visit with<br />
a pet to those in the community who may respond to the love<br />
and com<strong>for</strong>t of a pet therapy dog. VITAS has an affiliation with<br />
the Central Florida Toy Dog Club which has sister organizations<br />
throughout the <strong>state</strong>. Volunteers and their pets are trained to<br />
assist patients and their families in any setting.<br />
4. Other Conditions: VITAS has conditioned its application on the<br />
provision it will meet or exceed the following operational and<br />
programmatic indicators:<br />
• Establish satellite hospice offices in Baker and Nassau Counties<br />
during the first year of operation.<br />
• Implement a Tele<strong>Care</strong> Program consisting of 24/7 nurse<br />
availability to begin immediately.<br />
• Establish a Local Ethics Committee to begin upon certification,<br />
as discussed in Schedule B Section E2 of this application.<br />
• Implementation of <strong>Care</strong>PlanlT, a handheld bedside clinical<br />
in<strong>for</strong>mation system, by the end of the second year of operation.<br />
<strong>Care</strong>PlanlT is discussed in Schedule B Section E2.<br />
• Provide palliative radiation, chemotherapy and transfusions as<br />
appropriate <strong>for</strong> treating symptoms.<br />
• Provision of hospice services 24 hours a day, seven days a week<br />
as indicated by the patient's medical condition.<br />
• VITAS will admit all eligible patients without regard to their<br />
ability to pay.<br />
• Commit to having every patient being assessed by a physician<br />
upon admission to the hospice. Medical directors provide<br />
patient visits in their residence.<br />
• Medical directors must also be board-certified in hospice or<br />
palliative care medicine, or apply <strong>for</strong> board-certification within<br />
five years of employment.<br />
• RNs are encouraged to become certified in hospice and palliative<br />
care nursing. By the second year of operation, 50 percent of all<br />
supervisory nurses will attain such certification.<br />
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CON Action Number: 10061-10065<br />
• Chaplains are Masters of Divinity, demonstrated by completion<br />
of accredited CPE program.<br />
• Social workers are Master's level or licensed clinical social<br />
workers.<br />
• Designate a hospice representative to provide community<br />
outreach, promote hospice awareness and enhance access to<br />
African-American individuals in Subdistrict 4A.<br />
• A physician will serve as a member on every care team and<br />
provide patient visits as required.<br />
• Although bereavement services are generally provided to the<br />
family <strong>for</strong> one year after the death of the patient, services will be<br />
available beyond one year, if needed.<br />
• VITAS agrees that it will not solicit and will not accept<br />
donations from hospice patients, their families or the general<br />
community. VITAS will provide alternative hospice and charity<br />
in<strong>for</strong>mation to VITAS patients and their families and members<br />
of the community seeking to donate funds to hospice services.<br />
• Establish a clinical pastoral education program to begin<br />
immediately. The program description is found in TAB 10.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution in the amount of $300,000 to Florida State College<br />
at Jacksonville to fund an Endowed Teaching Chair,<br />
Scholarships, and the Northeast Florida Initiative <strong>for</strong> Nursing<br />
Work<strong>for</strong>ce Diversity. This will be initiated during its first year of<br />
licensure and will be measured via a signed declaratory<br />
<strong>state</strong>ment by VITAS and evidence of funds transferred. The<br />
correspondence between VITAS and Florida State College<br />
describing the uses of the donation is found in TAB 11.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution to United Way of Northeast Florida in the amount<br />
of up to $500,000 during the first three years of licensure. The<br />
United Way will serve as a charitable advisor to VITAS<br />
identifying not-<strong>for</strong>-profit organizations in need of funding. The<br />
charitable contribution condition will be measured via a signed<br />
declaratory <strong>state</strong>ment by VITAS and evidence of funds<br />
transferred. The correspondence between VITAS and United<br />
Way of Northeast Florida describing the donation process is<br />
found behind TAB 11.<br />
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CON Action Numbers: 10061-10065<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution to the Jacksonville Urban League in the amount of<br />
$50,000 during the first year of licensure. The contribution will<br />
be used to expand several health and quality-of-life initiatives<br />
currently in place at Jacksonville Urban League <strong>for</strong> a client base<br />
which is predominantly the underserved African-American<br />
population. The charitable contribution condition will be<br />
measured via a signed declaratory <strong>state</strong>ment by VITAS and<br />
evidence of funds transferred. The correspondence between<br />
VITAS and the Jacksonville Urban League describing the uses<br />
of the donation is found in TAB 11.<br />
b. Chapter 59C-1.0355, Florida Administrative Code contains the<br />
following general provisions and review criteria to be considered in<br />
reviewing hospice programs.<br />
(1) Required Program Description (Rule 59C-1.0355(6), Florida<br />
Administrative Code): An applicant <strong>for</strong> a new hospice program<br />
shall provide a detailed program description in its certificate<br />
of need application, including:<br />
(a) Proposed staffing, including use of volunteers.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) <strong>state</strong>s it will provide staff to equal or exceed State of<br />
Florida and Medicare guidelines. Compassionate <strong>Care</strong>‟s<br />
Schedule 6A indicates 34.9 FTEs in year one (ending June<br />
30, 2011) and 52.1 FTEs in year two (ending June 30, 2012).<br />
Compassionate <strong>Care</strong> <strong>state</strong>s it will utilize an interdisciplinary<br />
team model. The applicant <strong>state</strong>s that by including a wide<br />
range of personnel skills and experience and input from the<br />
family, Compassionate <strong>Care</strong> believes that the patient and the<br />
family are the primary unit of care. Other members of the<br />
care team include: patient‟s primary hospice physician,<br />
hospice medical director, registered nurse, social worker,<br />
certified home health aides/nursing assistants, therapists (to<br />
be utilized on a contractual basis), dieticians, bereavement<br />
counselors, chaplains, and trained volunteers. Additional<br />
staff will be added as needed. This applicant includes an inhouse<br />
physician as do co-batched applicants Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Collier County, Inc. and VITAS <strong>Health</strong>care<br />
Corporation of Florida.<br />
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CON Action Number: 10061-10065<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s it will provide each patient and family with a “Circle of<br />
<strong>Care</strong>”; an interdisciplinary team of its employees and the<br />
patient‟s physician dedicated to providing a high-level of care<br />
and assistance to patients and their families as designed and<br />
in use by the applicant. The interdisciplinary team is <strong>state</strong>d<br />
to be specialized in end-of-life care and in pain and symptom<br />
management. The manager of the interdisciplinary team is<br />
the nurse who assesses the needs of the patient and family.<br />
The applicant <strong>state</strong>s that in addition to the nurse case<br />
manager, the patient‟s attending physician and the medical<br />
director, the interdisciplinary team also includes the<br />
following: a home health care aide (<strong>for</strong> direct patient care); a<br />
chaplain (addressing concerns of a spiritual nature); a social<br />
worker (addressing psycho-social needs of patients and<br />
family members); trained volunteers (<strong>for</strong> companionship and<br />
supportive non-medical services); a bereavement coordinator<br />
(to manage support groups, newsletters and referrals) and an<br />
on-call nursing team. The applicant‟s Schedule 6A indicates<br />
a total of 17.7 FTE‟s dedicated to serving the program in year<br />
one (ending December 31, 2011) and 25.0 FTE‟s in year two<br />
(ending December 31, 2012). This applicant includes an inhouse<br />
physician, as do co-batched applicants<br />
Compassionate <strong>Care</strong> Hospice and VITAS <strong>Health</strong>care<br />
Corporation of Florida.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
notes, from Schedule 6A, a total of 41.0 FTEs in year one<br />
(ending December 31, 2011) and 62.84 FTEs in year two<br />
(ending December 31, 2012). Categories of staff include the<br />
following: administration; medical director (by contract<br />
<strong>state</strong>d in schedule assumptions); nursing; dietary and social<br />
services. The applicant primarily identifies direct patient<br />
care volunteers and indirect patient care volunteers. As<br />
implied, the direct patient care volunteers provide com<strong>for</strong>t,<br />
support and/or practical assistance to adults and children.<br />
The Volunteer Vigil Program is within this category. Indirect<br />
patient care volunteers provide administrative assistance or<br />
special projects that enhance the work of in-house staff,<br />
supporting patients, families and the ef<strong>for</strong>ts of teams in the<br />
field.<br />
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CON Action Numbers: 10061-10065<br />
United Hospice of Florida, Inc. (CON #10064) notes, from<br />
Schedule 6A, a total of 16.97 FTEs in year one (ending date<br />
not <strong>state</strong>d) and 44.35 FTEs in year two (ending date not<br />
<strong>state</strong>d). Categories of staff include the following:<br />
administration; physician (by contract), nursing, ancillary<br />
(by contract), dietary, and social services. Schedule 6A<br />
agrees with the applicant‟s staff table <strong>for</strong> year one average<br />
number of FTEs (16.97 FTEs, <strong>for</strong> year one) but <strong>for</strong> year two,<br />
the table <strong>state</strong>s an average number of FTEs of 42.76<br />
compared to the Schedule 6A total of 44.35 FTEs.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
notes, from Schedule 6A, a total of 17.49 FTEs in year one<br />
(ending June 2011) and 39.08 FTEs in year two (ending<br />
June 2012). Categories of staff include the following:<br />
administration, physician, nursing, ancillary (by contract<br />
and including dietary staff) and social services. This<br />
applicant includes an in-house physician, as do co-batched<br />
applicants Compassionate <strong>Care</strong> Hospice and Odyssey <strong>Health</strong><br />
<strong>Care</strong> of Collier County.<br />
(b) Expected sources of patient referrals.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) <strong>state</strong>s that patient referrals are expected to come<br />
from numerous sources, including physicians, hospital<br />
social workers and case managers, long-term care facilities,<br />
other community-based agencies, and family members and<br />
others. The applicant <strong>state</strong>s it has started to develop<br />
relationships with area health care providers and social<br />
service agencies in Hospice Service Area 4A and will continue<br />
to do so once approved. The applicant intends to educate<br />
the existing providers about the types of services it can<br />
provide to their patients. The applicant has conditioned <strong>for</strong><br />
a full-time staff member, located in the City of Jacksonville<br />
to serve all five counties, to serve exclusively as an outreach<br />
coordinator to the non-health care community.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s it will actively seek referrals through physicians; longterm<br />
care facilities (including nursing homes and assisted<br />
living facilities/adult care centers), hospitals, patients/<br />
patient families, and managed care and insurance<br />
companies. The applicant notes interest in ALF providers,<br />
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CON Action Number: 10061-10065<br />
included support letters from local ALFs in the area and<br />
provides materials on such relationships (CON Application<br />
#10062, Appendix I-Odyssey and Assisted Living). Though<br />
the applicant <strong>state</strong>s it is in the process of obtaining<br />
memoranda of understanding <strong>for</strong> general inpatient contracts<br />
<strong>for</strong> local Hospice Service Area 4A providers, Odyssey is the<br />
sole co-batched applicant that lacked a commitment letter to<br />
enter into a written inpatient bed arrangement <strong>for</strong> hospice<br />
services, should the project be approved.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
comments that hospice is often called upon as an<br />
“intervention”, as if impending death was somehow not<br />
<strong>for</strong>eseen and that many frail elderly of advanced age are, in<br />
fact, terminal, as no more curative options are available.<br />
Considering this, Seasons <strong>state</strong>s interest in more outreach<br />
and education toward more timely hospice care. In this<br />
context, the applicant expects referrals from nursing homes,<br />
hospitals, assisted living facilities, comprehensive medical<br />
rehabilitation facilities, long-term care hospitals, physicians,<br />
families, individuals, advocates <strong>for</strong> the homeless, advocates<br />
of AIDS and HIV+ groups, and military related organizations<br />
within the area. While the applicant <strong>state</strong>s interest in<br />
outreach to these groups, letters of support do not bear out<br />
due diligence in reaching out to these groups local to<br />
Hospice Service Area 4A, with the exception of one letter of<br />
support from a Clay County long-term care hospital –<br />
Kindred Hospital North Florida. However, the applicant<br />
conditions to contribute (within six months of final CON<br />
approval) $50,000 of outreach, promotion and expansion of<br />
hospice services in Clay County, release to the local area the<br />
Seasons Hospice & Palliative <strong>Care</strong> Newsletter, PharmSmart<br />
and a local advisory board to address local hospice needs in<br />
Hospice Service Area 4A.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s that<br />
referrals are expected from: physicians; hospitals; nursing<br />
homes; other health care providers; family members and<br />
patients. The applicant has 17 letters of support from a<br />
combination of local hospitals, SNFs, ALFs, organizations <strong>for</strong><br />
the homeless and ministerial/social service organizations.<br />
The applicant conditions, particularly, toward outreach to<br />
African Americans, the homeless and rural areas in the<br />
hospice service area, with a staff member dedicated to this<br />
purpose.<br />
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CON Action Numbers: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>report</strong>s 23 successful hospice start-ups in the past decade<br />
and <strong>state</strong>s it has the ability to enter a community with<br />
established hospices and develop referral sources. The<br />
applicant expects referrals from: physicians, hospitals,<br />
clergy, social service agencies, disease advocacy groups,<br />
nursing homes and other health care providers, family<br />
members and patients. The applicant has letters of support<br />
from organizations <strong>for</strong> the aged; minority affiliates, health<br />
care centers (including a local FQHC), ALFs, nursing homes,<br />
hospitals, social service agencies, <strong>state</strong>, county and city<br />
elected officials. This applicant conditions that a designated<br />
hospice representative will provide community outreach,<br />
promote hospice awareness and enhance access to African<br />
Americans in the service area and make charitable<br />
contributions of $300,000 to the Florida State College/<br />
Northeast Florida Initiative <strong>for</strong> Nursing Work<strong>for</strong>ce Diversity<br />
Program, up to $500,000 to the United Way of Northeast<br />
Florida and $50,000 to the Jacksonville Urban League. The<br />
applicant has letters of support from these organizations.<br />
(c) Projected number of admissions, by payer type,<br />
including Medicare, Medicaid, private insurance, selfpay,<br />
and indigent care patients <strong>for</strong> the first two years of<br />
operation.<br />
The table below is provided, to illustrate projected<br />
admissions <strong>for</strong> years one and two <strong>for</strong> each of the co-batched<br />
applicants.<br />
Total Projected Admissions By Applicant<br />
<strong>for</strong> Years One and Two<br />
CON # Applicant Year One Year Two Both Years<br />
10061 Compassionate 275 415 690<br />
10062 Odyssey 155 271 426<br />
10063 Seasons 402 615 1,017<br />
10064 United Hospice 222 528 750<br />
10065 VITAS <strong>Health</strong>care 162 297 459<br />
Source: CON Application #s 10061-10065.<br />
As indicated in the table above, Seasons (CON #10063)<br />
anticipates serving a total of 1,017 patients in the first two<br />
combined years, the most of any co-batched applicant, while<br />
Odyssey (CON #10062) anticipates serving a total of 426<br />
patients in the first two combined years, the fewest of any<br />
co-batched applicant. As described in the tables <strong>for</strong> each co-<br />
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CON Action Number: 10061-10065<br />
batched applicant below, Odyssey (CON #10062) anticipates<br />
serving the highest percentage of Medicare patients in the<br />
first two years of operation and Compassionate <strong>Care</strong> (CON<br />
#10061) anticipates serving the lowest percentage of<br />
Medicare patients in the same period. Compassionate <strong>Care</strong><br />
(CON #10061) projects to serve 32 self-pay/uncompensated<br />
patients, followed by Seasons (CON #10063) with 25<br />
charity/uncompensated patients, Odyssey (CON #10062)<br />
with 17 commercial/charity/other patients, United (CON<br />
#10064) with seven indigent patients and VITAS (CON<br />
#10065) with five indigent patients 13 . It is noted that<br />
hospice programs are required by federal and <strong>state</strong> law to<br />
provide services to everyone requesting them, regardless of<br />
ability to pay.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) provides estimates as shown below regarding<br />
admissions by payer type in the first two years of operation.<br />
Expected Admissions by Payer Type<br />
For Compassionate <strong>Care</strong> Hospice of Florida, Inc. - CON #10061<br />
Hospice Service Area 4A<br />
Payer Type Year One Year Two<br />
Medicare 209 324<br />
Medicaid 14 21<br />
Commercial/Other 28 62<br />
Self-Pay/Uncompensated 24 8<br />
Total 275 415<br />
Source: CON Application #10061, page #61.<br />
As shown in the table above, the applicant intends to serve<br />
275 and 415 patients in its first and second year of<br />
operation, respectively. Medicare will comprise 76.0 percent<br />
of admissions during the first year and 78.07 percent during<br />
the second year of operations. Self-pay/uncompensated care<br />
is expected to comprise 8.73 percent in year one and 1.93<br />
percent in year two.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
provides estimates as shown below regarding admissions by<br />
payer type in the first two years of operation.<br />
13 Several applicants combine payer categories and it is not sure as to the actual number of<br />
indigent/charity care patients they project to serve. A self-pay patient could be paying <strong>for</strong> care. It<br />
appears that Seasons with 25 patients listed as charity/uncompensated may propose to serve more<br />
charity care patients than Compassionate <strong>Care</strong> which includes self-pay. Odyssey includes commercial<br />
and „other‟ in its charity patient numbers.<br />
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CON Action Numbers: 10061-10065<br />
Projected Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc.<br />
d/b/a Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida<br />
Admissions by Payer CON #10062<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Payer Type Year One Year Two<br />
Medicare 144 252<br />
Medicaid 5 8<br />
Commercial/Charity/Other 6 11<br />
Total 155 271<br />
Source: CON Application #10062, page #95.<br />
As shown in the table above, the applicant intends to serve<br />
155 and 271 patients in its first and second year of<br />
operation, respectively. Medicare will comprise 92.90<br />
percent of admissions during the first year and 92.99<br />
percent during the second year of operations. Commercial/<br />
charity/other is expected to comprise 3.87 percent in year<br />
one and 4.06 percent in year two.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
provides estimates as shown below regarding admissions by<br />
payer type in the first two years of operation.<br />
Expected Admissions by Payer Type<br />
For Seasons Palliative <strong>Care</strong> of Florida, Inc. #10063<br />
Hospice Service Area 4A<br />
Payer Type Year One Year Two<br />
Medicare 354 541<br />
Medicaid 16 25<br />
3 rd Party Insurance 20 31<br />
Self-Pay 2 3<br />
Charity/Uncompensated 10 15<br />
Other 0 0<br />
Total 402 615<br />
Source: CON Application #10063, Table 1-10 on page #1-36.<br />
As shown in the table above, the applicant intends to serve<br />
402 and 615 patients in its first and second year of<br />
operation, respectively. Medicare will comprise 88.06<br />
percent of admissions during the first year and 87.97<br />
percent of admissions during the second year of operations.<br />
Self-pay care is expected to be 0.50 percent in year one and<br />
0.49 percent in year two, while charity/uncompensated care<br />
is expected to be 2.49 percent in year one and 2.44 percent<br />
in year two.<br />
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CON Action Number: 10061-10065<br />
United Hospice of Florida, Inc. (CON #10064) provides<br />
estimates as shown below regarding admissions by payer<br />
type in the first two years of operation.<br />
Expected Admissions by Payer Type<br />
For United Hospice of Florida, Inc. - CON #10064<br />
Hospice Service Area 4A<br />
Payer Type Year One Year Two<br />
Medicare 205 488<br />
Medicaid 11 26<br />
Indigent 2 5<br />
Insurance/Managed <strong>Care</strong>/Other 4 9<br />
Total 222 528<br />
Source: CON Application #10064, page #109.<br />
As shown in the table above, the applicant intends to serve<br />
222 and 528 patients in its first and second year of<br />
operation, respectively. Medicare will comprise 92.34<br />
percent of admissions during the first year and 92.42<br />
percent of admissions during the second year of operations.<br />
Indigent care is expected to be 0.90 percent in year one and<br />
0.95 percent in year two.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
provides estimates as shown below regarding admissions by<br />
payer type in the first two years of operation.<br />
Expected Admissions by Payer Type<br />
For VITAS <strong>Health</strong>care Corporation of Florida - CON #10065<br />
Hospice Service Area 4A<br />
Payer Type Year One Year Two<br />
Medicare 149 273<br />
Medicaid 8 15<br />
Indigent 2 3<br />
Private Insurance/Self-Pay/Other 3 6<br />
Total 162 297<br />
Source: CON Application #10065, page #67.<br />
As shown in the table above, the applicant intends to serve<br />
162 and 297 patients in its first and second year of<br />
operation, respectively. Medicare will comprise 91.98<br />
percent of admissions during the first year and 91.92<br />
percent of admissions during the second year of operations.<br />
Indigent care is expected to be 1.23 percent in year one and<br />
1.01 percent in year two, while private/self-pay/other care is<br />
expected to be 1.85 percent in year one and 2.02 percent in<br />
year two.<br />
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CON Action Numbers: 10061-10065<br />
(d) Projected number of admissions, by type of terminal<br />
illness, <strong>for</strong> the first two years of operation.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) provides the following table illustrating the<br />
projected number of admissions by type of terminal illness<br />
<strong>for</strong> the first two years of operation.<br />
Projected number of Admissions by Diagnosis<br />
For Compassionate <strong>Care</strong> Hospice of<br />
Florida, Inc./CON #10061<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Disease Year One Year Two<br />
Cancer 100 151<br />
Non-cancer 175 264<br />
Total 275 415<br />
Source: CON Application #10061, page #62.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
provides the following table illustrating the projected number<br />
of admissions by type of terminal illness <strong>for</strong> the first two<br />
years of operation.<br />
Projected Admissions by Diagnosis <strong>for</strong> Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Collier County, Inc.<br />
d/b/a Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida/CON #10062<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Disease Year One Year Two<br />
Cancer 48 84<br />
Alzheimer‟s/Dementia 22 38<br />
Congestive Heart Failure 26 46<br />
COPD 14 24<br />
Debility 19 33<br />
Renal 5 8<br />
Liver/Other 21 38<br />
Total 155 271<br />
Source: CON Application #10062, page #95.<br />
The applicant projects to serve 155 patients in year one and<br />
271 patients in year two.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
provides the following table illustrating the projected number<br />
of admissions by type of terminal illness <strong>for</strong> the first two<br />
years of operation.<br />
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CON Action Number: 10061-10065<br />
Projected Admissions by Diagnosis <strong>for</strong> Seasons Palliative <strong>Care</strong><br />
of Florida, Inc./CON #10063<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Disease Year One Year Two<br />
Cancer 146 224<br />
Non- Cancer 256 392<br />
Total 402 616<br />
Source: CON Application #10063, page #1-38.<br />
The applicant‟s table 1-13 indicates that it projects to serve<br />
402 patients in year one and 615 patients in year two.<br />
However, year two computes to 616 admissions.<br />
United Hospice of Florida, Inc. (CON #10064) provides the<br />
following table illustrating the projected number of<br />
admissions by type of terminal illness <strong>for</strong> the first two years<br />
of operation.<br />
Projected Admissions by Diagnosis <strong>for</strong> United Hospice of<br />
Florida, Inc. - CON #10064<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Disease Year One Year Two<br />
Cancer 44 106<br />
HIV/AIDS 9 15<br />
Respiratory 20 46<br />
Cardiac 68 161<br />
Renal Failure 12 22<br />
Alzheimer/Cerebral Degeneration 25 57<br />
Cerebrovascular/Stroke 19 46<br />
Other 23 75<br />
Total 222 528<br />
Source: CON Application #10064, page #110.<br />
The applicant projects to serve 222 patients in year one and<br />
528 patients in year two.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
provides the following table illustrating the projected number<br />
of admissions by type of terminal illness <strong>for</strong> the first two<br />
years of operation.<br />
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CON Action Numbers: 10061-10065<br />
Projected Admissions by Diagnosis <strong>for</strong> VITAS <strong>Health</strong>care<br />
Corporation of Florida - CON #10065<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Disease Year One Year Two<br />
Cancer 52 95<br />
HIV/AIDS 2 3<br />
Respiratory 13 23<br />
Cardiac 22 41<br />
Renal Failure 2 4<br />
Alzheimer/Cerebral Degeneration 34 62<br />
Cerebrovascular/Stroke 10 20<br />
Other 27 49<br />
Total 162 297<br />
Source: CON Application #10065, page #68.<br />
The applicant projects to serve 162 patients in year one and<br />
297 patients in year two.<br />
(e) Projected number of admissions, by two age groups,<br />
under 65 and 65 or older, <strong>for</strong> the first two years of<br />
operation.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) projects 275 admissions in its first year of<br />
operations and 415 in the second year. The projected<br />
number of admissions by age groups under 65 and 65 or<br />
older appears in the following table.<br />
Projected Number of Admissions by Age Group<br />
<strong>for</strong> Compassionate <strong>Care</strong> Hospice of Florida/CON #10061<br />
Years One and Two of Operation<br />
Service Area 4A<br />
Under 65 65 or Older Total<br />
Year One 61 214 275<br />
Year Two 92 323 415<br />
Source: CON Application #10061, page #62.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
projects 155 admissions in its first year of operations and<br />
271 in the second year. The projected number of admissions<br />
by age groups under 65 and 65 or older appears in the<br />
following table.<br />
80
CON Action Number: 10061-10065<br />
Projected Number of Admissions by Age Group <strong>for</strong> Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey <strong>Health</strong><strong>Care</strong> of<br />
Central Florida/CON #10062<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Under 65 65 or Older Total<br />
Year One 16 139 155<br />
Year Two 27 244 271<br />
Source: CON Application #10062, page #95.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
projects 402 admissions in its first year of operations and<br />
615 in the second year. The projected number of admissions<br />
by age groups under 65 and 65 or older appears in the<br />
following table.<br />
Projected Number of Admissions by Age Group <strong>for</strong> Seasons<br />
Palliative <strong>Care</strong> of Florida, Inc./CON #10063<br />
Years One and Two of Operation<br />
Hospice Service Area 4A<br />
Under 65 65 or Older Total<br />
Year One 89 313 402<br />
Year Two 136 480 615<br />
Source: CON Application #10063, page #1-38.<br />
The applicant‟s total year two admissions count is <strong>state</strong>d to<br />
be 615; however, year two adds up to 616 admissions in<br />
tables 1-11 and 1-13.<br />
United Hospice of Florida, Inc. (CON #10064) projects 222<br />
admissions in its first year of operations and 528 in the<br />
second year. The projected number of admissions by age<br />
groups under 65 and 65 or older appears in the following<br />
table.<br />
Projected Number of Admissions by Age Group<br />
<strong>for</strong> United Hospice of Florida, Inc./CON #10064<br />
Years One and Two of Operation<br />
Service Area 4A<br />
Under 65 65 or Older Total<br />
Year One 29 193 222<br />
Year Two 69 459 528<br />
Source: CON Application #10064, page #110.<br />
81
CON Action Numbers: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
projects 162 admissions in its first year of operations and<br />
297 in the second year. The projected number of admissions<br />
by age groups under 65 and 65 or older appears in the<br />
following table.<br />
Projected Number of Admissions by Age Group<br />
<strong>for</strong> VITAS <strong>Health</strong>care Corporation of Florida/CON #10065<br />
Years One and Two of Operation<br />
Service Area 4A<br />
Under 65 65 or Older Total<br />
Year One 23 139 162<br />
Year Two 42 255 297<br />
Source: CON Application #10065, page #68.<br />
(f) Identification of the services that will be provided<br />
directly by hospice staff and volunteers and those that<br />
will be provided through contractual arrangements.<br />
The hospice care team shall directly provide the following<br />
core services: nursing services, social work services, pastoral<br />
or counseling services, dietary counseling, and bereavement<br />
counseling services. Physician services may be provided by<br />
the hospice directly or through contract. A hospice may also<br />
use contracted staff if necessary to supplement hospice<br />
employees in order to meet the needs of patients during<br />
periods of peak patient loads or under extraordinary<br />
circumstances.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061)<br />
asserts that it will provide what it lists as core services –<br />
physician, nursing, social work, pastoral and counseling,<br />
bereavement counseling, home health aide, pharmacy,<br />
supplies and durable medical equipment, homemaker and<br />
chore, and dietician/nutritionist – all directly through<br />
hospice staff and volunteers. Compassionate <strong>Care</strong> <strong>state</strong>s<br />
intent to contract <strong>for</strong> the following services: physical,<br />
occupational and speech therapy, massage, music, inpatient<br />
and respite, patient transportation, and infusion.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
asserts that with the exception of physicians and a minimal<br />
level of contract services by physical, speech and<br />
occupational therapists, the majority of services will be<br />
provided by the hospice care team and volunteers. The<br />
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CON Action Number: 10061-10065<br />
applicant indicates in-house services are as follows: home<br />
health care aides, chaplain, social worker, volunteers,<br />
bereavement coordinator, and a 24/7 on-call nursing team.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
<strong>state</strong>s that Seasons will provide directly the following four<br />
core service care categories: routine, respite, inpatient, and<br />
continuous. Seasons indicates staff will provide the<br />
following services: physician, nursing, medical social<br />
services, counseling (spiritual and bereavement), hospice<br />
aide, and homemaker, dietician and music therapy. Seasons<br />
also <strong>state</strong>s a preference to hire a hospice medical director<br />
but that in seeking to fill the position, contracted<br />
professionals will be used. Other professionals to be<br />
contracted are as follows: speech, occupational, respiratory<br />
and physical therapy.<br />
United Hospice of Florida, Inc. (CON #10064) will provide<br />
what it lists as core services – physician, nursing, social<br />
work, pastoral counseling, bereavement counseling and<br />
dietary counseling – all directly through hospice staff and<br />
volunteers. The applicant also <strong>state</strong>s that massage, pet and<br />
aroma therapy services will be provided by staff and<br />
volunteers. United indicates it will contract <strong>for</strong> durable<br />
medical equipment, pharmacy, rehabilitation, and certain<br />
clinical services (not otherwise specified by the applicant).<br />
United has letters of support from sister entities within the<br />
United umbrella to meet this need.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>state</strong>s that it will provide what it lists as core services –<br />
physician, nursing, social work, pastoral counseling and<br />
dietary counseling – all directly through hospice staff and<br />
volunteers. The applicant anticipates all services will be<br />
provided by hospice staff with the exception of durable<br />
medical equipment and supplies and pharmacy services.<br />
From time to time, the applicant <strong>state</strong>s there may be a need<br />
<strong>for</strong> supplemental staff employed to meet patient need, such<br />
as physical therapy, speech-language pathology, massage<br />
and occupational therapy.<br />
83
CON Action Numbers: 10061-10065<br />
(g) Proposed arrangements <strong>for</strong> providing inpatient care.<br />
All of the co-batched applicants, except Odyssey, include<br />
support letters from hospital and/or skilled nursing facilities<br />
in Service Area 4A that are willing to contract with the<br />
applicant <strong>for</strong> inpatient hospice services.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061)<br />
anticipates contractual arrangements with existing hospitals<br />
in each of the five Hospice Service Area 4A counties.<br />
Compassionate <strong>Care</strong> has letters of support from James<br />
Wood, President and CEO, Memorial Hospital-Jacksonville<br />
(Duval County) and from Thomas Pentz, Chief Executive<br />
Officer, Orange Park Medical Center (Clay County) stating<br />
their willingness to enter into agreements with<br />
Compassionate <strong>Care</strong> to provide inpatient care <strong>for</strong><br />
Compassionate <strong>Care</strong> patients.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s plans <strong>for</strong> contractual arrangements with hospitals,<br />
nursing homes and other appropriate settings. According to<br />
the applicant, it will seek similar agreement that it already<br />
has with these types of facilities through Odyssey<br />
<strong>Health</strong><strong>Care</strong>-Daytona (Volusia County) and Odyssey<br />
<strong>Health</strong><strong>Care</strong>-Miami/Dade (Miami-Dade County). The<br />
applicant further <strong>state</strong>s it is in the process of obtaining such<br />
memoranda of understanding locally in Hospice Service Area<br />
4A. However, the applicant is the only co-batched applicant<br />
to fail to secure such commitments through letters of<br />
support.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
<strong>state</strong>s it has experience in opening and operating hospice<br />
houses and inpatient units and that it expects to provide<br />
inpatient services with hospitals and nursing homes. The<br />
applicant includes a support letter agreeing to enter into a<br />
contractual relationship from Hoyt Ross, Chief Executive<br />
Officer, Kindred Hospital - North Florida (Clay County).<br />
United Hospice of Florida, Inc. (CON #10064) expresses<br />
interest in having contractual relationships with nursing<br />
homes and hospitals designed to meet patient needs in the<br />
hospice service area. Four facilities make specific reference<br />
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CON Action Number: 10061-10065<br />
to entering into contractual agreements in the delivery of<br />
inpatient services to the applicant‟s hospice patients, should<br />
the applicant be approved: River Point Behavioral <strong>Health</strong><br />
Center and Wekiva Springs Center <strong>for</strong> Women (Duval<br />
County), Life <strong>Care</strong> Center of Orange Park (Clay County), and<br />
Quality <strong>Health</strong> of Fernandina Beach (Nassau County).<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>state</strong>s that it will utilize inpatient beds <strong>for</strong> hospice patients<br />
in existing local hospitals and nursing homes. Further, the<br />
applicant anticipates a need <strong>for</strong> 297 bed days in the second<br />
year of operation. Per VITAS, many more beds than those<br />
projected will be contracted <strong>for</strong> on an as-needed basis. Six<br />
Hospice Service Area 4A skilled nursing facilities expressed<br />
commitment or interest in entering into appropriate<br />
agreements to provide inpatient hospice beds, should this<br />
applicant be approved. These providers are as follows: Chris<br />
Adams, Executive Director; Harts Harbor <strong>Health</strong> <strong>Care</strong><br />
Center; Elizabeth Sholar, NHA, Fleet Landing; Raymond<br />
Prudencio, NHA, CNA, Administrator and Preceptor, The<br />
Terrace at Fleming Island (Clay County); Glen<strong>for</strong>d Wright,<br />
MSHRM, BSBA, Administrator, West Jacksonville <strong>Health</strong> and<br />
Rehabilitation Center; Jerry Tomack, MHSA, NHA, Executive<br />
Director, San Jose <strong>Health</strong> and Rehabilitation Center and Eric<br />
Weisz, Executive Director, Governor‟s Creek <strong>Health</strong> and<br />
Rehabilitation Center (Clay County).<br />
(h) Proposed number of inpatient beds that will be located in<br />
a freestanding inpatient facility, in hospitals, and in<br />
nursing homes.<br />
None of the applicants provided the number of inpatient<br />
beds they would use through the service area‟s hospitals or<br />
nursing homes. An existing provider, Community Hospice of<br />
North East Florida has three inpatient hospice facilities<br />
licensed <strong>for</strong> 70 beds in Jacksonville. The projects do not<br />
involve a freestanding inpatient hospice facility.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061)<br />
estimates that 1.3 percent of total patient days will be<br />
required <strong>for</strong> inpatient admissions. The applicant <strong>state</strong>s this<br />
will be achieved through contractual agreements with<br />
hospitals, nursing homes and freestanding hospice facilities<br />
in the area.<br />
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CON Action Numbers: 10061-10065<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
does not offer a number of expected inpatient beds that will<br />
be needed. The applicant indicates beds will be contracted<br />
on an as-needed basis.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
does not offer a number of expected inpatient beds that will<br />
be needed. The applicant indicates beds will be contracted<br />
on an as-needed basis, envisioning its own inpatient facility<br />
at some point in the future.<br />
United Hospice of Florida, Inc. (CON #10064) does not<br />
offer a number of expected inpatient beds that will be<br />
needed. The applicant indicates beds will be contracted on<br />
an as-needed basis.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
does not offer a number of expected inpatient beds that will<br />
be needed, other than anticipating a need <strong>for</strong> 297 bed days<br />
in its second year of operation. The applicant indicates beds<br />
will be contracted on an as-needed basis.<br />
(i) Circumstances under which a patient would be admitted<br />
to an inpatient bed.<br />
All co-batched applicants express an interest in admitting<br />
patients to an inpatient bed when less intensive methods of<br />
care are impractical, unfeasible, ineffective or otherwise<br />
inappropriate, given patient desires, symptoms and caregiver<br />
or family dynamics.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) <strong>state</strong>s that staff, in coordination with the<br />
interdisciplinary team, after consultation with the attending<br />
physician, will evaluate each patient on a case-by-case basis<br />
to determine admission to an inpatient facility. Some major,<br />
broad categories of consideration in reaching this decision<br />
are: pain, other symptoms (imminent death, home support<br />
break-down, nutritional and/or medication challenges, other<br />
complications, etc.) and psychosocial pathology (disturbed<br />
mental <strong>state</strong>, depression/anxiety in the extreme, unsafe<br />
home environment, disruption in family dynamics, etc.).<br />
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CON Action Number: 10061-10065<br />
Compassionate <strong>Care</strong> <strong>state</strong>s that it will provide respite care<br />
when the patient‟s family/caregiver needs a short period of<br />
relief. This will be offered on an “as needed” basis <strong>for</strong> a<br />
maximum of five days per respite admission <strong>for</strong> a<br />
Medicare/Medicaid patient. For patients covered by other<br />
insurers, the duration may be approved <strong>for</strong> a longer period of<br />
time.<br />
The applicant conditions to provide at least 1.5 percent of<br />
total patient days to continuous care and to have continuous<br />
care staff at bedside within two hours of receipt of a request<br />
<strong>for</strong> such service and will continue it as long as needed.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s admission to an inpatient bed is dictated by a<br />
patient‟s medical need and if possible, symptoms are<br />
addressed and care is provided in the “home” setting<br />
wherever that may be. However, per the applicant, inpatient<br />
care applies when care cannot be effectively managed in the<br />
home setting, when continuous care is not an option due to<br />
the level of caregiver support available, or patient or family<br />
wishes call <strong>for</strong> this care. The applicant <strong>state</strong>s that patients<br />
are encouraged to seek the level of care with which they are<br />
most com<strong>for</strong>table, including inpatient hospice care. To meet<br />
this need, the applicant <strong>state</strong>s intent to secure inpatient<br />
contracts with hospitals and nursing homes in Hospice<br />
Service Area 4A. However, the applicant stresses a focus on<br />
allowing the patient to remain in their home setting at all<br />
times and is committed to providing continuous care, to<br />
which the applicant conditions but does not condition a<br />
given percent of patient days.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
<strong>state</strong>s primarily inpatient bed admission is based on pain<br />
control, symptom management and <strong>for</strong> respite purposes.<br />
Seasons notes respite care will be provided “only on an<br />
occasional basis” and <strong>for</strong> no longer than five days at a time.<br />
This applicant does not condition to a given percentage of<br />
patient days to continuous care.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s the<br />
primary factors in the inpatient admission decision are the<br />
patient‟s physical condition, which fluctuates with time, and<br />
the home care situation. Pain and symptom control are<br />
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CON Action Numbers: 10061-10065<br />
<strong>state</strong>d to be major considerations. The patient, family,<br />
physician and the interdisciplinary team are <strong>state</strong>d to be<br />
part of the evaluation process in making an inpatient<br />
placement decision. The applicant conditions to 2.5 percent<br />
of total patient days by the end of year two are dedicated to<br />
continuous care services.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>state</strong>s the primary factors in the inpatient admission<br />
decision are the patient‟s physical condition and the home<br />
care situation. Respite care may be provided (up to five<br />
days). VITAS conditions to the highest percentage of patient<br />
days to continuous care of at least 3.0 percent.<br />
(j) Provisions <strong>for</strong> serving persons without primary<br />
caregivers at home.<br />
All co-batched applicants <strong>state</strong> that they have mechanisms<br />
and procedures in place to address patient needs <strong>for</strong> serving<br />
persons without primary caregivers at home.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061)<br />
indicates that it does not require that a patient have a<br />
caregiver in the home to be part of their program. The<br />
applicant <strong>state</strong>s it has provided care to individuals in<br />
boarding homes, homeless shelters, psychiatric centers, and<br />
correctional facilities and that it serves all patients including<br />
those who live alone, transients, and those who have AIDS,<br />
or are homeless. The applicant <strong>state</strong>s that if a homeless<br />
patient desiring Compassionate <strong>Care</strong> Hospice care is<br />
discharged from a hospital and has nowhere to go,<br />
Compassionate <strong>Care</strong> will place them in an inpatient unit and<br />
apply <strong>for</strong> Medicaid. Once the patient qualifies and receives<br />
Medicaid, they will be placed into a long-term care<br />
environment in which hospice care can still be provided as<br />
long as the patient requires such care.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s that it accepts all patients who meet admission<br />
criteria, including patients who do not have a primary care<br />
giver at home, the homeless and patients with AIDS. The<br />
applicant explains that an Odyssey nurse will coordinate<br />
appropriate <strong>action</strong> and placement with the rest of the<br />
interdisciplinary team and hospice physician or attending<br />
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physician. Odyssey describes numerous mechanisms to<br />
address admissions and placement (CON Application<br />
#10062, page #83 and Appendix F - Policies & Procedures<br />
Matrix).<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
expects that some persons will not have a designated person<br />
who can function as the primary caregiver. The team leader<br />
will identify and direct safe and effective provision of hospice<br />
care in situations where the terminally ill patient requires<br />
assistance with self-care and skilled services. The applicant<br />
<strong>state</strong>s that care will be provided in a location in accordance<br />
with the patient‟s wishes. The applicant indicates that a<br />
comprehensive patient and family assessment will be<br />
completed to determine the degree of care needed. The<br />
applicant provides its Policy on Persons without Primary<br />
<strong>Care</strong>givers in Exhibit 4-3 (CON Application #10063,<br />
page #4-50).<br />
United Hospice of Florida, Inc. (CON #10064) commits to<br />
serving those who do not have a primary caregiver, the<br />
homeless and those with AIDS. United, more than any other<br />
co-batched applicant provides substantial letters of support<br />
from organizations that serve the homeless in the area and<br />
conditions to serve selected homeless shelter facilities and<br />
organizations, many of whom would not have a primary<br />
caregiver. The applicant <strong>state</strong>s it will request a caregiver<br />
upon admission and if a caregiver is not identified, United<br />
Hospice <strong>state</strong>s it will develop, as part of the plan of care, a<br />
means by which daily care and safety needs of the patient<br />
will be met. It is further <strong>state</strong>d the applicant will seek to<br />
assist in developing a caregiver network, when needed. If a<br />
caregiver arrangement cannot be established in the least<br />
restrictive environment practical, the applicant <strong>report</strong>s it<br />
may recommend placement in an ALF or SNF, in which<br />
residential care would be available.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>state</strong>s that if a patient lives alone and a caregiver is not<br />
nearby and able to care <strong>for</strong> the patient, VITAS will assist the<br />
patient in developing an applicable network. VITAS will also<br />
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recommend qualified adult sitter services, if applicable and<br />
provided a financial hardship is not created. According to<br />
the applicant, nursing home and ALF options will be<br />
considered <strong>for</strong> patients that are not able to care <strong>for</strong><br />
themselves and lack a caregiver support group.<br />
(k) Arrangements <strong>for</strong> the provision of bereavement services.<br />
Here is a brief summary of each applicant‟s comments on<br />
bereavement services. According to the applicant‟s policy,<br />
Compassionate <strong>Care</strong>’s (CON #10061) on-going<br />
bereavement services are concluded at the end of 13 months,<br />
though the applicant <strong>state</strong>s these services are available up to<br />
15 months after a patient‟s death. Compassionate <strong>Care</strong> also<br />
references a pediatric bereavement program called<br />
Compassionate Courage. Odyssey (CON #10062) indicates<br />
bereavement services will be available 12-13 months, post<br />
death, conditions <strong>for</strong> 0.5 FTEs <strong>for</strong> a dedicated bereavement<br />
coordinator and conditions <strong>for</strong> a children‟s bereavement<br />
camp in Florida by the end of the first year in operation.<br />
Seasons (CON #10063) conditions <strong>for</strong> Kangaroo Kids and<br />
Kangaroo Camp and provides <strong>for</strong> bereavement services <strong>for</strong><br />
not less than 13 months. United Hospice (CON #10064)<br />
provides <strong>for</strong> bereavement services <strong>for</strong> up to 13 months after<br />
the patient‟s death or longer if needed but does not condition<br />
<strong>for</strong> any given bereavement services, though does <strong>state</strong> that<br />
Camp Cocoon will be available to children in the service<br />
area. VITAS (CON #10065) conditions that while<br />
bereavement services are generally provided <strong>for</strong> one year (12<br />
months) after the death of the patient, services will be<br />
available beyond one year, if needed.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061)<br />
<strong>state</strong>s that it will provide bereavement services to the<br />
surviving family members <strong>for</strong> up to 15 months after the<br />
patient‟s death. However, according to the applicant‟s<br />
policy 14 , on-going bereavement is concluded at the end of 13<br />
months if the bereaved is no longer in need of bereavement<br />
services. Bereavement services will begin with an initial<br />
bereavement risk assessment to be completed by the social<br />
worker, bereavement coordinator or designee within three<br />
days of admission or at the earliest convenience of the<br />
patient/family/caregiver. The applicant <strong>state</strong>s that the<br />
14 CON Application #10061, Appendix Q-Bereavement Services/Policy #2003.7:Procedure #11.<br />
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bereavement coordinator may also provide supportive<br />
counseling prior to the death of the patient but within two<br />
weeks after the death of the patient, a sympathy card will be<br />
sent to the bereaved.<br />
Bereavement counselors work with patients and families to<br />
assist with coping, grief work, and bereavement care and<br />
teach grieving families how to find healthy paths to healing.<br />
Trained volunteer counselors may be assigned to make<br />
regular contacts. Compassionate <strong>Care</strong> further <strong>state</strong>s that a<br />
pediatric-oriented program called Compassionate Courage<br />
will be made available, what the applicant calls a Children‟s<br />
Bereavement Network. In summary, this program is<br />
designed to provide support to children dealing with “a<br />
significant loss”, does not seek to achieve resolution of a<br />
child‟s grief but provides support and teaches coping skills.<br />
Compassionate <strong>Care</strong> offers no bereavement conditions in its<br />
Schedule C.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s bereavement services begin with an initial assessment<br />
by an Odyssey nurse (an RN) during patient admission and<br />
continue after the patent‟s death. The bereavement<br />
coordinator is a part of the psychosocial/interdisciplinary<br />
team. The applicant <strong>state</strong>s it offers the following<br />
bereavement activities and services: condolence<br />
correspondence, written materials, articles, and resources,<br />
one-on-one counseling, bereavement letters, grief support<br />
groups, memorial services, and a holiday bereavement<br />
program. Odyssey <strong>state</strong>s it has been contacted by local<br />
hospitals <strong>for</strong> assistance with the families of dying patients<br />
not on hospice service and though not reimbursable <strong>for</strong><br />
Odyssey, the staff has provided bereavement services to<br />
provide support to the non-hospice as well as hospital staff.<br />
According to the applicant‟s policy 15 , a bereavement<br />
coordinator will contact the bereaved within 15 days<br />
following patient death and bereavement services will be<br />
available <strong>for</strong> 12-13 months, post death.<br />
15 CON Application #10062, Appendix F-Policies & Procedures Matrix: Policy #15.7-Bereavement<br />
Services.<br />
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16 http://www.cetacanyon.org/contact.php<br />
CON Action Numbers: 10061-10065<br />
Through the Odyssey Vista<strong>Care</strong> Foundation (the<br />
Foundation), the applicant <strong>state</strong>s it offers “SKY Camp” – a<br />
free weekend camp <strong>for</strong> children ages seven to 17 grieving the<br />
death of a loved one. SKY Camp opened in 1998 at Ceta<br />
Canyon Camp & Retreat Center 16 (a ministry of the<br />
Northwest Texas Conference of the United Methodist<br />
Church, located in Happy, Texas). Children attend the camp<br />
as guests of the Foundation. This is at no charge to their<br />
families. Stated activities at the camp are: swimming,<br />
basketball, volleyball, ping-pong, and the challenge course -<br />
physical challenges designed <strong>for</strong> the various age groups<br />
(such as climbing, balancing and teamwork). In essence,<br />
this program is designed to reduce feelings of isolation and<br />
fear, and then to help the survivors move on. SKY Camp<br />
also includes family support groups and individual grief<br />
counseling. The applicant conditions <strong>for</strong> 0.5 FTEs the first<br />
year of operation <strong>for</strong> development ef<strong>for</strong>ts regarding<br />
community bereavement programs in the area which will<br />
extend beyond the families of patients admitted to Odyssey<br />
<strong>Health</strong><strong>Care</strong>. The applicant further conditions that the<br />
Odyssey Vista<strong>Care</strong> Hospice Foundation will facilitate the<br />
provision of a children‟s bereavement camp in Florida by the<br />
end of the first year of operation, similar to Odyssey‟s SKY<br />
Camp, Camp Healing Tree and Camp Odyssey.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
considers bereavement services as a core service that must<br />
be provided to complete the applicant‟s “Circle of <strong>Care</strong>”. The<br />
duration of bereavement care is <strong>state</strong>d to vary, depending on<br />
the need. Seasons indicates bereavement services will be<br />
offered following the death of a hospice patient <strong>for</strong> not less<br />
than 13 months, to the extent desired by the bereaved and<br />
such services will not be terminated except by the request of<br />
the bereaved or upon referral of the family to outside<br />
agencies when mental health/family dynamics issues<br />
interfere with appropriate grieving. Assessments, by the<br />
interdisciplinary team, are part of this process. At least one<br />
memorial service per year <strong>for</strong> bereaved family members and<br />
significant others will be hosted by Seasons. Kangaroo Kids<br />
and Kangaroo Camp are conditioned by the applicant,<br />
designed <strong>for</strong> terminally-ill children.<br />
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17 CON Application #10065, Tab 22.<br />
CON Action Number: 10061-10065<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s<br />
bereavement counseling will be provided by a staff social<br />
worker or chaplain to family members and significant others.<br />
This service will be offered <strong>for</strong> a minimum of up to 13<br />
months after the patient‟s death or longer if needed. The<br />
applicant is prepared to address differing interventions. At<br />
the time of the patient‟s admission, an assessment of<br />
survivor risk factors will become part of the bereavement<br />
care plan. Social workers and chaplains are to review this<br />
plan quarterly. What United calls core grief services include<br />
the following: grief counseling, home visits, bereavement<br />
group activities, volunteer support, patient/family education<br />
materials, quarterly follow-up/correspondence, memorial<br />
gatherings, sympathy cards, assistance with memorial<br />
services, community resources and referrals, staff<br />
bereavement support, and community education/relations.<br />
The applicant indicates that through the United Hospice<br />
Foundation (the Foundation), there are various bereavement<br />
care initiatives, with “Camp Cocoon” being the most<br />
significant, per the applicant. This is a three day<br />
bereavement camp <strong>for</strong> children ages five through 17 held<br />
each summer in north Georgia. The camp is designed to<br />
provide positive and creative outlets <strong>for</strong> children who have<br />
suffered the loss of a close loved one and is operated by<br />
volunteers, primarily employees of United. Some of these<br />
volunteers are <strong>state</strong>d to be physicians, nurses, social<br />
workers, Chaplains bereavement coordinators and others.<br />
The applicant indicates that Camp Cocoon will be made<br />
available to children grieving the loss of a loved one in<br />
Hospice Service Area 4A. However, the applicant does not<br />
condition that Camp Cocoon will be made available to the<br />
Hospice Service Area 4A population, nor does it condition <strong>for</strong><br />
any given bereavement service activity, per se.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>state</strong>s that staff and volunteers provide bereavement<br />
services, which according to the applicant are appropriate<br />
from the time of nursing assessment until mourning is<br />
accomplished and the survivor can emotionally reinvest into<br />
life and other relationships. The applicant provides three<br />
bereavement VITAS publications and materials 17 , including<br />
the 54-page, The Surviving Spouse (by J Richard Williams,<br />
MD), the 16-page Children & Grief and the 20-page Teens &<br />
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CON Action Numbers: 10061-10065<br />
Grief. The applicant indicates that while services are<br />
generally provided <strong>for</strong> one year (12 months) after the death of<br />
the patient, services will be available beyond one year, if<br />
needed, and this is conditioned. Support is <strong>state</strong>d to be<br />
available 24/7 through a toll-free phone number with a<br />
trained psychosocial staff person available. What VITAS<br />
calls core grief services include the following: grief<br />
counseling, home visits, bereavement group activities,<br />
volunteer support, patient/family education materials,<br />
quarterly follow-up/correspondence, memorial gatherings,<br />
sympathy cards, assistance with memorial services,<br />
community resources and referrals, staff bereavement<br />
support, and community education/relations. The<br />
bereavement program will be directed by a VITAS<br />
volunteer/bereavement manager and supported by a<br />
Chaplain. Features of the program are as follows:<br />
bereavement assessment, development of the bereavement<br />
plan of care, home visits, written contacts with family (at<br />
intervals of one, three, six, nine, 12 and 15 months),<br />
telephone contact, counseling, and referral. At the time of<br />
patient death, a bereavement packet is provided, an<br />
invitation to bereavement groups and memorial gatherings.<br />
There is also staff bereavement support.<br />
(l) Proposed community education activities concerning<br />
hospice programs.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON<br />
#10061) <strong>state</strong>s that it tailors its services and program<br />
offerings to the unique needs of the communities in which it<br />
serves. Compassionate <strong>Care</strong> <strong>state</strong>s that it is committed to<br />
providing community education activities concerning hospice<br />
programs to residents of Hospice Service Area 4A. The<br />
applicant <strong>state</strong>s that most hospices market primarily to<br />
hospitals, nursing homes, assisted living operators and<br />
physicians. Reflective of this, the applicant conditions <strong>for</strong> a<br />
full time dedicated staff member, located in the City of<br />
Jacksonville (Duval County) to reach all five counties, with<br />
the exclusive responsibility of serving as a community<br />
outreach coordinator to the non-health care community.<br />
Schedule 6A specifically itemizes 1.0 FTE <strong>for</strong> a community<br />
liaison in year one and 1.5 FTE in year two.<br />
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CON Action Number: 10061-10065<br />
The applicant includes written education materials regarding<br />
hospice care specifically designed <strong>for</strong> health providers. The<br />
applicant conditions that it will conduct extensive<br />
community education and outreach programs, itemizing the<br />
groups it intends to target <strong>for</strong> education (CON Application<br />
#10061, Schedule C).<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
conditions that it will have a minimum of three community<br />
education representatives, expanding community awareness<br />
of hospice services and educating local medical staff,<br />
community leaders and potential hospice patients as to the<br />
benefit of and availability of hospice care. Odyssey‟s<br />
Schedule 6A does not show FTEs <strong>for</strong> these positions. The<br />
applicant also conditions <strong>for</strong> various other educational<br />
programs, such as in-service training (components of<br />
Odyssey University) resources to the community, including<br />
nursing homes, assisted living facilities and the Council on<br />
Aging. Also conditioned are: in-service training to registered<br />
nurses, social workers, administrators and other staff, with<br />
the applicant conditioning to host at least one seminar<br />
annually during the first two years of operation <strong>for</strong> clergy<br />
and community faith leaders (The Clergy End of Life<br />
Education Program), to enhance spiritual support <strong>for</strong><br />
hospice patients in the area.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
<strong>state</strong>s the provision of hospice education through many<br />
venues: printed material, commercial spots on television and<br />
radio, articles in newspapers and magazines, testimonials in<br />
person at service clubs, women‟s clubs, churches,<br />
synagogues, schools, community colleges and universities.<br />
The applicant <strong>state</strong>s that it will target hospitals, nursing<br />
homes and ALFs. Seasons <strong>state</strong>s it is already a provider of<br />
continuing education credits <strong>for</strong> nurses. According to<br />
Seasons, it publishes, free of charge, a newsletter – “Seasons<br />
Hospice & Palliative <strong>Care</strong>”, “Guide <strong>for</strong> Patients Families and<br />
Friends/Enhancing the Quality of Time” and “Tender Legal<br />
<strong>Care</strong>”. Seasons <strong>state</strong>s that it will integrate Hospice Service<br />
Area 4A into its main website (www.Seasons.org), to keep<br />
costs down and offer a uni<strong>for</strong>m message, consistent with the<br />
applicant‟s mission and vision. This applicant conditions to,<br />
within six months of project final approval, donate $50,000<br />
(to the Clay County Board of County Commissioners) to<br />
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CON Action Numbers: 10061-10065<br />
promote outreach and education of hospice services. It also<br />
conditions to publish at least one edition of each newsletter<br />
(Seasons Hospice & Palliative <strong>Care</strong> and PharmSmart) by the<br />
end of the first year of operation.<br />
United Hospice of Florida, Inc. (CON #10064) plans a<br />
tailored African-American outreach program that will<br />
coordinate educational sessions, presentations and listening<br />
sessions. United Hospice staff is planned to educate nursing<br />
home and ALF constituents on myths and benefits of<br />
hospice. The applicant also plans to host hospice<br />
educational events at senior organizations, religious affiliated<br />
groups, Veterans organizations and health fairs and educate<br />
residents of rural areas of Baker and Nassau Counties and<br />
more. The applicant conditions <strong>for</strong> a staff member that is<br />
responsible <strong>for</strong> outreach initiatives to plan events and serve<br />
as a key contact with African-American community leaders.<br />
United‟s Schedule 6A shows 2.0 FTEs in year one and 3.0<br />
FTEs in year two <strong>for</strong> hospice representatives. The applicant<br />
conditions to sponsor two to four education seminars per<br />
year <strong>for</strong> physicians, long-term care facilities and ALFs.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
proposes to educate the service area through public <strong>for</strong>ums,<br />
such as seminars and community education at churches,<br />
schools and other social organizations. The applicant<br />
identifies other specific organizations it would target <strong>for</strong><br />
hospice education: the Florida <strong>Health</strong> <strong>Care</strong> Association, the<br />
Florida Assisted Living Association, the Florida Association<br />
Directors of Nursing <strong>Administration</strong>, American Legion,<br />
Veterans of Foreign Wars Chapter, local nursing homes,<br />
local ALFs and United Way, among others (not <strong>state</strong>d). The<br />
applicant plans to address education as it has done in its<br />
hospice operations in the following Florida hospice service<br />
areas: 4B, 7A, 7B, 7C, 8B, 9C, 10, and 11. Conditioned<br />
contributions to Florida State College at Jacksonville<br />
($300,000), United Way of Northeast Florida (up to<br />
$500,000) and the Jacksonville Urban League ($50,000) are<br />
all <strong>state</strong>d as mechanisms to educate the community about<br />
hospice.<br />
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(m) Fundraising activities.<br />
CON Action Number: 10061-10065<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061)<br />
<strong>state</strong>s that it does not intend to engage to a great extent in<br />
fundraising to support its ongoing operations. Nonetheless,<br />
it participates in limited fundraising activities, primarily<br />
through bequests and family gifts, and makes use of such<br />
funding when appropriate, through the ef<strong>for</strong>ts and <strong>action</strong>s of<br />
its related Compassionate <strong>Care</strong> Hospice Foundation, Inc.<br />
(the Foundation), a non-profit organization <strong>state</strong>d to be<br />
based in Newark, Delaware. Compassionate <strong>Care</strong> <strong>state</strong>s the<br />
Foundation is designed to provide financial assistance to<br />
terminally ill patients and families in need. Additionally, it<br />
supports public programs to provide the general public with<br />
in<strong>for</strong>mation about the end-of-life choice so that individuals<br />
can determine and communicate their wishes and help their<br />
families prepare <strong>for</strong> the future.<br />
None of its funds are used <strong>for</strong> provision of direct hospice<br />
care; rather it is available to assist when financial difficulty<br />
overwhelms families and places them under untenable<br />
stress, per Compassionate <strong>Care</strong>. Compassionate <strong>Care</strong><br />
Hospice Foundation provides services in instances that are<br />
typically not covered or reimbursed by insurance, according<br />
to the applicant. Compassionate <strong>Care</strong> <strong>state</strong>s it will not<br />
compete with other extensive fund raising activities that are<br />
already well developed and important to support existing<br />
providers in the area; however, the applicant does not<br />
condition that it will refrain from active fundraising.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062)<br />
<strong>state</strong>s it will not per<strong>for</strong>m any fundraising activities in direct<br />
support of its programs but will support existing communitybased<br />
fundraising ef<strong>for</strong>ts such as those of local health care<br />
support groups and the existing hospice provider (singular),<br />
as well as the fundraising of the parent‟s “Dream<br />
Foundation”. Per the applicant, through the parent (Odyssey<br />
<strong>Health</strong>care), the Odyssey Vista<strong>Care</strong> Hospice Foundation<br />
contributed nearly $5.8 Million in charity care in 2008 and<br />
more than $878,000 in 2007. The applicant does not<br />
condition that it will refrain active fundraising.<br />
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CON Action Numbers: 10061-10065<br />
The applicant conditions that through the parent (Odyssey<br />
<strong>Health</strong><strong>Care</strong>) or the Odyssey Vista<strong>Care</strong> Hospice Foundation a<br />
$25,000 contribution will be made to an appropriate not-<strong>for</strong>profit<br />
entity in the community to fund education <strong>for</strong> end-oflife<br />
issues.<br />
The applicant offers numerous instances of nonreimbursable<br />
events and services provided by Odyssey<br />
<strong>Health</strong><strong>Care</strong>-Daytona. The applicant is non-specific on when<br />
the events took place and does not offer an estimate of the<br />
cumulative or individual costs of the services described.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063)<br />
<strong>state</strong>s it has a number of specialized programs and services<br />
that are not part of the benefits of Medicare, Medicaid or<br />
insurance but are nevertheless needed <strong>for</strong> palliative care at<br />
the end-of-life. Efficiency and volunteer time is <strong>state</strong>d to offset<br />
many of these costs. Seasons <strong>state</strong>s it is in the process<br />
of developing a special non-profit foundation to<br />
accommodate donations and if the project is approved, when<br />
the non-profit foundation materializes, its resources would<br />
be made available <strong>for</strong> Hospice Service Area 4A use. The<br />
applicant <strong>state</strong>s that fundraising <strong>for</strong> hospice is a<br />
combination of sponsorship, partnership, corporate and<br />
locally driven by appreciation. Seasons indicates donations<br />
are often given without being sought. The applicant does not<br />
affirmatively <strong>state</strong>, nor does it condition, that it will refrain<br />
from actively seeking donations through fundraising ef<strong>for</strong>ts.<br />
Seasons <strong>state</strong>s that since it cannot count upon donations as<br />
a steady revenue stream, it works diligently to negotiate<br />
rates with insurers and other local and <strong>state</strong> programs to<br />
cover costs.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s that<br />
it does not actively raise funds from the community and<br />
there<strong>for</strong>e does not compete with non-profit hospice<br />
organizations or other groups in obtaining funds from the<br />
community; however, this is not conditioned. The applicant<br />
claims that as a result of not actively raising funds from the<br />
community, it will not dilute potential contributions<br />
available in the community or adversely impact existing<br />
hospice programs‟ fundraising ef<strong>for</strong>ts. The applicant <strong>state</strong>s<br />
it will “give back” by conditioning CON approval to the<br />
following: providing hospice services to the homeless in<br />
shelters, monthly health screenings <strong>for</strong> the homeless and<br />
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3. Statutory Review Criteria<br />
CON Action Number: 10061-10065<br />
contributions of a $2,000 scholarship each year to four<br />
students who are studying nursing, pharmacy or therapy,<br />
and have an interest in end-of-life care.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
<strong>state</strong>s it does not and will not actively raise funds or accept<br />
donations, from the community. VITAS is the only cobatched<br />
applicant to condition that it will refrain from this<br />
activity. The applicant <strong>state</strong>s it encourages that such<br />
donations go to charities that support the hospice‟s mission<br />
or to the charity of the donator‟s choice. VITAS <strong>state</strong>s that it<br />
will not dilute potential contributions available in the<br />
community or adversely impact existing hospice programs‟<br />
fundraising ef<strong>for</strong>ts.<br />
a. Is need <strong>for</strong> the project evidenced by the availability, quality of care,<br />
accessibility and extent of utilization of existing health care<br />
facilities and health services in the applicant’s service area?<br />
ss. 408.035(1)(a) and (b), Florida Statutes.<br />
Need <strong>for</strong> an additional hospice program is evidenced by the availability,<br />
accessibility and extent to utilization of existing health care facilities and<br />
health services in this service area. The co-batched applicants are<br />
responding to published need of one hospice program in Hospice Service<br />
Area 4A.<br />
The following chart illustrates the increase in hospice admissions <strong>for</strong> the<br />
past five years, in Hospice Service Area 4A. As shown below, admissions<br />
have increased from 4,581 in the year ending June 30, 2004 to 5,783 in<br />
the year ending June 30, 2009.<br />
Hospice Admissions <strong>for</strong> Service Area 4A<br />
Fiscal Years 2004 – 2009<br />
Fiscal Year Admissions<br />
07/08 – 06/09<br />
07/07 – 06/08<br />
07/06 – 06/07<br />
07/05 – 06/06<br />
07/04 – 06/05<br />
07/03 – 06/04<br />
99<br />
5,783<br />
5,628<br />
5,064<br />
4,969<br />
4,763<br />
4,581<br />
Source: AHCA Florida Need Projections <strong>for</strong> Hospice Programs, Fiscal Years 2004-2009.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061) notes that<br />
three licensed hospice providers offer services in the hospice service area.<br />
This applicant also notes continued hospice admission growth from 2002
CON Action Numbers: 10061-10065<br />
through 2009 and in the above table, the <strong>Agency</strong> verifies steady growth<br />
<strong>for</strong> each 12-month period since at least June 2004. The applicant<br />
proposes locate offices in the following three counties to meet demand:<br />
Duval, Clay, and St. Johns. The applicant justifies offices in Clay and St.<br />
Johns Counties by stating these are the second and third largest<br />
counties, respectively, by population, in the hospice service area.<br />
The applicant asserts that it is committed to providing the highest<br />
quality care possible to terminally ill patients and their families and will<br />
continue to respond to future needs of the community, as it has done at<br />
other locations in which it operates.<br />
The applicant provides the fewest number of local support letters,<br />
providing the weakest evidence of all co-batched applicants that it has<br />
local support to provide the hospice services it proposes in Hospice<br />
Service Area 4A.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) proposes “special and not<br />
normal” circumstances to justify its proposal, in addition to the <strong>Agency</strong>‟s<br />
published need. These specific terminally ill populations that the<br />
applicant has identified as not being adequately served are as follows:<br />
cancer patients age 65 years and older, non-cancer patients under the<br />
age of 65 years, and non-cancer patients age 65 years and older. The<br />
applicant also <strong>state</strong>s that introduction of a new hospice in the area will<br />
improve quality of care through increased competition.<br />
One of the hallmarks of the applicant‟s <strong>state</strong>d increased quality is patient<br />
admission within three hours after receiving a physician‟s order <strong>for</strong><br />
hospice care; however, the <strong>Agency</strong> notes that this is not conditioned by<br />
the applicant. Odyssey believes that its proposal to provide three or<br />
more dedicated community education representatives will significantly<br />
increase public awareness of the benefits of hospice services. Odyssey<br />
also <strong>state</strong>s intentions to be cost-effective, have a level of patient-focused<br />
care not currently available to the Hospice Service Area 4A and will<br />
expand the existing hospice market to reach a wider base of patients<br />
(through service-based competition). The applicant also focuses on<br />
disaster planning and promotes “green” initiatives to be more<br />
environmentally friendly. Odyssey and co-batched applicant Seasons<br />
Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) are the only two of the cobatched<br />
applicants that do not <strong>state</strong> that rural residents of the hospice<br />
service area lack access to and availability of hospice care. This is the<br />
only co-batched applicant that <strong>state</strong>s that all diagnostic groups are<br />
underserved. The applicant does condition <strong>for</strong> hospice services<br />
specifically designed <strong>for</strong> the Hispanic population (and other minorities<br />
100
CON Action Number: 10061-10065<br />
not specified) and is the only co-batched applicant to condition <strong>for</strong><br />
serving the Hispanic population but lacks any support letters from local<br />
or regional/<strong>state</strong> or national Hispanic organizations. The applicant‟s<br />
<strong>Care</strong>Beyond Program, a system designed to tailor plans of care specific to<br />
given diagnoses, is a feature of this applicant. The applicant believes<br />
efficiency will be improved by the overall weight of the parent‟s<br />
experience and size on a nationwide basis.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) <strong>state</strong>s that<br />
overall, hospice services are only palliative and are delivered at the endof-life<br />
to meet hospice patient needs. Seasons indicates that as hospices<br />
have closed in the area over the past several years, hospice patient<br />
growth has continued. Seasons challenges that self-<strong>report</strong>ing of<br />
measures and outcomes is adequate to <strong>for</strong>m conclusions about hospice<br />
services in the local area and that generally, access, availability and<br />
quality of care are questionable when self-<strong>report</strong>ed. As such, Seasons<br />
<strong>report</strong>s it is an advocate of external accreditation, such as by the Joint<br />
Commission, with trained surveyors, with consistently applied standards<br />
and measures. In this way, Seasons <strong>state</strong>s it can assure the public of<br />
meeting rigorous standards as assessed by external reviewers. Seasons<br />
proposes a condition to work with the <strong>Agency</strong> and the Department of<br />
Elder Affairs to develop and field test hospice outcome measures that will<br />
further enhance the data collected and promote program per<strong>for</strong>mance<br />
throughout the <strong>state</strong>. The cost of this endeavor will be borne by the<br />
applicant.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s a projected net<br />
need of 925 additional hospice program admissions <strong>for</strong> the January 2011<br />
Hospice Planning Horizon and that the most significant gap in hospice<br />
services is within non-cancer patients, with particular recognition of noncancer<br />
patients under 65 years of age. In addition to non-cancer<br />
patients, this applicant also targets other <strong>state</strong>d underserved populations<br />
in the area – African-Americans, the homeless, the mentally ill and rural<br />
residents of the area. The applicant conditions to reach each of these<br />
populations. The applicant also conditions <strong>for</strong> main offices in the City of<br />
Jacksonville, with satellites in Baker and Nassau Counties, to<br />
particularly reach the populations the applicant finds to currently have<br />
the least hospice access and availability. The applicant also finds that<br />
the UHS-Pruitt family of companies will be best suited to be a fully<br />
integrated model of care where patients can be most efficiently and easily<br />
transitioned as their hospice needs change, offering seamless support.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) <strong>state</strong>s that its<br />
operations would not materially impact volume at the existing hospices<br />
in the area. VITAS <strong>state</strong>s that as a matter of <strong>state</strong> policy, the need <strong>for</strong> an<br />
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CON Action Numbers: 10061-10065<br />
additional hospice project in the area is evidenced by the extent of<br />
utilization of existing hospice services in the area. The applicant<br />
conditions to reach the populations it identifies as most lacking hospice<br />
access and availability, that being terminally-ill non-cancer patients,<br />
African Americans and rural Baker County. VITAS like co-batched<br />
applicant Odyssey <strong>Health</strong>care of Collier County, Inc. (CON #10062)<br />
<strong>state</strong>s that it incorporates disaster planning into its operations. In<br />
summary, the applicant <strong>state</strong>s more experience providing hospice<br />
services in Florida and nationwide than any co-batched applicant. VITAS<br />
has the widest range of local and <strong>state</strong>-affiliated support letters of all cobatched<br />
applicants that propose to provide hospice services in Hospice<br />
Service Area 4A.<br />
b. Does the applicant have a history of providing quality of care? Has<br />
the applicant demonstrated the ability to provide quality care? ss.<br />
408.035 (1) (c), Florida Statutes.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) <strong>state</strong>s it is<br />
a newly <strong>for</strong>med entity and there<strong>for</strong>e has no operational history. However,<br />
Compassionate <strong>Care</strong> <strong>state</strong>s origination in 1993 and operation or approval<br />
to operate in the following 16 <strong>state</strong>s: Delaware, Florida (will become<br />
operational in February 2010); Georgia, Illinois, Kansas, Massachusetts,<br />
Michigan, Minnesota, Missouri, Nebraska, New Jersey, New York,<br />
Pennsylvania, South Dakota, Texas, and Wisconsin.<br />
The applicant includes copies of policies and procedures (CON<br />
Application #10061, Appendix S-Policies & Procedures) that address a<br />
wide range of hospice practices. Some of these policies and procedures<br />
include: incident <strong>report</strong>ing, clinical record review, summary satisf<strong>action</strong><br />
surveys, condition of participation <strong>for</strong>ms, annual evaluation, orientation,<br />
continuous care services, interdisciplinary team plan, complaint/<br />
grievance procedures, initial/comprehensive assessment, and many<br />
others. Compassionate <strong>Care</strong> <strong>state</strong>s its per<strong>for</strong>mance improvement plan is<br />
incorporated within Medicare conditions of participation, as required by<br />
Florida licensure rules. Compassionate <strong>Care</strong> <strong>state</strong>s it has extensive<br />
benchmarking and also attests to close monitoring and collection of<br />
measurable data on 15 separate events. Some of these include:<br />
medication errors, adverse drug re<strong>action</strong>s, patient falls, 911 calls,<br />
infection control, pain assessment and control review, satisf<strong>action</strong><br />
surveys, com<strong>for</strong>t within 48 hours of admission, and per<strong>for</strong>mance<br />
improvement. This applicant does not condition <strong>for</strong> seeking Joint<br />
Commission accreditation.<br />
102
CON Action Number: 10061-10065<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida/CON #10062 (Odyssey or OHCCF) is<br />
the sole shareholder of Odyssey <strong>Health</strong><strong>Care</strong> Operating B, LP, a wholly<br />
owned subsidiary of Odyssey. The parent is <strong>state</strong>d to have 92 Medicarecertified<br />
hospice programs spread among 29 <strong>state</strong>s. The parent‟s<br />
existing Florida hospice programs (Odyssey <strong>Health</strong><strong>Care</strong>-Daytona and<br />
Odyssey <strong>Health</strong><strong>Care</strong>-Miami/Dade) are <strong>state</strong>d to have an ADC of 111.7<br />
and 288 patients, respectively over the 10-month period ending October<br />
2009. Odyssey <strong>Health</strong><strong>Care</strong>-Daytona and Odyssey <strong>Health</strong><strong>Care</strong>-<br />
Miami/Dade have over 34,000 and 79,000 patient days, respectively,<br />
over the same period. The applicant <strong>state</strong>s that Odyssey has received the<br />
Pioneer Award, the GM Circle of Excellence Award and the Mission<br />
Award. If CON approved, the applicant anticipates establishing and<br />
operating a hospice program in Hospice Service Area 4AB, with the speed<br />
and efficiency that it did when approved to operate hospice programs in<br />
Hospice Service Areas 4B and 11. The applicant <strong>state</strong>s that Odyssey<br />
hospice programs are members of the National Hospice and Palliative<br />
<strong>Care</strong> Organization, and are Medicare and Medicaid certified or are<br />
pursuing said certification. The applicant says it will adopt and practice<br />
the same standards of quality and efficiency that are promoted by the<br />
parent. The applicant conditions that it will become accredited by the<br />
Joint Commission and the National Institute <strong>for</strong> Jewish Hospice by the<br />
end of its second year of operation.<br />
For the three-year period ending January 15, 2010, the parent‟s Odyssey<br />
<strong>Health</strong><strong>Care</strong>-Daytona and Odyssey <strong>Health</strong><strong>Care</strong>-Miami/Dade have one<br />
confirmed complaint, per <strong>Agency</strong> records. The confirmed complaint is<br />
medicine problem/error/<strong>for</strong>mulary.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) is a Florida <strong>for</strong>profit<br />
corporation and development stage company <strong>for</strong>med on October<br />
29, 2009 <strong>for</strong> the purpose of operating a hospice in Florida. Seasons<br />
<strong>state</strong>s it admitted 9,290 persons during the 12-month period ending<br />
October 31, 2009.<br />
The applicant <strong>report</strong>s a quality assessment and per<strong>for</strong>mance<br />
improvement program, to reflect the complexity of the organization and<br />
its services, including services provided by contract (CON Application<br />
#10063, Exhibit 4-1/Overview of Policy and Procedures <strong>for</strong> Quality<br />
Assessment & Per<strong>for</strong>mance Improvement and Sentinel Events). The<br />
103
CON Action Numbers: 10061-10065<br />
applicant also provides currently active Joint Commission accreditation<br />
certificates <strong>for</strong> its affiliate hospice operations in the following <strong>state</strong>s:<br />
Delaware, Cali<strong>for</strong>nia, Illinois, and Texas. No other co-batched applicant<br />
offers Joint Commission certifications. The applicant conditions that<br />
within the first two years of operation Seasons will begin the preparatory<br />
activities to be accredited by the Joint Commission.<br />
United Hospice of Florida, Inc. (CON #10064) <strong>state</strong>s it is a newly<br />
<strong>for</strong>med corporation and there<strong>for</strong>e has no operating history. However, the<br />
applicant is a wholly owned subsidiary of United <strong>Health</strong> Services of<br />
Florida, Inc., a member of the UHS-Pruitt family of companies. United<br />
<strong>report</strong>s owning 25 hospices throughout the Southeast (in the <strong>state</strong>s of<br />
Georgia, North Carolina and South Carolina). Per the applicant, UHS<br />
has a strong demonstrated history of providing high quality of care, with<br />
a <strong>report</strong>ed regulatory compliance history of no deficiencies in conditions<br />
of Medicare participation, no Medicare CAP issues, has never been<br />
investigated by an OIG and has never had to adhere to court ordered<br />
corporate integrity agreements. United <strong>state</strong>s that in 2002, UHS<br />
committed to the Quality First Pledge, which the applicant <strong>state</strong>s is<br />
rooted in seven different principles that cultivated an environment of<br />
continuous quality improvement, openness/transparency and<br />
leadership. UHS <strong>state</strong>s support <strong>for</strong> the American <strong>Health</strong> <strong>Care</strong><br />
Association's definition of quality: the totality of features and<br />
characteristics of services that meet or exceed customer expectation and<br />
need. UHS <strong>state</strong>s an expectation of quality to be reflective of its<br />
per<strong>for</strong>mance in the delivery of health care services each and every day.<br />
The applicant expects to be an innovator in a seamless and superior<br />
health care delivery system to the community it serves. The applicant<br />
claims adherence to the United Hospice quality assessment/per<strong>for</strong>mance<br />
improvement plan [CON Application #10064, Tab 17]. United Hospice<br />
conditions that it will seek and obtain CHAP accreditation upon<br />
certification.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) is a <strong>for</strong>-profit<br />
operating entity in Florida. VITAS <strong>state</strong>s it has provided hospice services<br />
since 1978, has an average daily census of 4,547 patients and serves<br />
more than 16,000 patients and family annually. VITAS has licensed<br />
hospice programs in the following eight Florida hospice service areas: 4B<br />
(Flagler and Volusia Counties), 7A (Brevard County), 7B (Orange and<br />
Osceola Counties), 7C (Seminole County), 8B (Collier County), 9C (Palm<br />
Beach County), 10 (Broward County), and 11 (Miami-Dade and Monroe<br />
Counties).<br />
104
CON Action Number: 10061-10065<br />
VITAS <strong>state</strong>s its quality assurance program is designed to meet and, in<br />
many cases, exceed those standards established by regulatory bodies.<br />
Program standards as developed by the National Hospice and Palliative<br />
<strong>Care</strong> Organization are <strong>state</strong>d to serve as the basis <strong>for</strong> all program<br />
components at VITAS. The purpose of the applicant‟s QI Program is to<br />
assure the provision of high quality patient and family care through the<br />
ongoing monitoring and evaluation of the quality, availability and<br />
appropriateness of the hospice services and therapies provided by VITAS.<br />
For the three-year period ending January 15, 2010, the VITAS family of<br />
Florida hospice operations spread throughout Hospice Service Areas 4B,<br />
7A, 7B, 7C, 8B, 9C, 10 and 11 have four confirmed complaints. The four<br />
confirmed complaints are one each <strong>for</strong> the following: discharge planning,<br />
lack of assessment, medicine problems/errors/<strong>for</strong>mulary and nursing<br />
services.<br />
c. What resources, including health manpower, management<br />
personnel, and funds <strong>for</strong> capital and operating expenditures, are<br />
available <strong>for</strong> project accomplishment and operation<br />
ss. 408.035(1)(d), Florida Statutes.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061): The<br />
financial impact of the project will include the project cost of $227,616<br />
and incremental operating costs in year two of $4,236,244. The<br />
applicant is a Florida <strong>for</strong>-profit corporation and a development stage<br />
company that was <strong>for</strong>med on September 19, 2007 <strong>for</strong> the purpose of<br />
operating a hospice in Florida, with net assets of $40,000 and $49,900 in<br />
liabilities <strong>for</strong> the period ended December 15, 2009. At the date of the<br />
audit, no operating results were available. Without results from<br />
operations, an analysis of the short and long-term strength of the<br />
applicant cannot be made.<br />
Capital Requirements:<br />
Schedule 2 indicates total capital projects of $1,020,075 which consist of<br />
the CON subject to this review, CON #10000 <strong>for</strong> a hospice in District 4B,<br />
and $500,000 in other capitalization. In addition, the applicant will have<br />
to fund the projected year one operating loss of $330,083.<br />
Available Capital:<br />
The applicant provided a letter from its parent corporation,<br />
Compassionate <strong>Care</strong> Hospice Group, Ltd. which <strong>state</strong>s it will provide<br />
funding <strong>for</strong> the project. In support of this <strong>state</strong>ment, the applicant<br />
provided a letter from JPMorgan showing a $1,500,000 line of credit, and<br />
indicates that the entire line of credit is available to the parent. It should<br />
be noted that the applicant included operating results of its parent.<br />
105
CON Action Numbers: 10061-10065<br />
Because the parent‟s operating results were unaudited, the <strong>Agency</strong> did<br />
not consider them in this review.<br />
Staffing:<br />
Schedule 6A indicates <strong>for</strong> year one ending June 30, 2011, the applicant<br />
<strong>for</strong>ecasts 34.9 FTEs as follows: administration, 5.5 FTEs; physicians, 0.3<br />
FTEs; nursing, 24.6 FTEs; ancillary, 1.0 FTEs; dietary 0.5 FTEs and<br />
social services, 3.0 FTEs. In the second year ending June 30, 2012 the<br />
applicant <strong>for</strong>ecasts 52.1 FTEs as follows: administration, 7.0 FTEs;<br />
physicians, 0.6 FTEs; nursing, 39.0 FTEs; ancillary, 1.0 FTEs; dietary<br />
0.0 FTEs and social services, 4.5 FTEs.<br />
Conclusion:<br />
Funding <strong>for</strong> the project should be available as needed.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062): The financial impact of<br />
the project will include the project cost of $666,972 and incremental<br />
operating costs in year two of $2,650,443. The applicant is a Florida <strong>for</strong>profit<br />
corporation, incorporated on October 18, 2006, <strong>for</strong> the purpose of<br />
operating a hospice and related businesses in the State of Florida. As of<br />
December 31, 2008, the applicant had no assets and $227,731 in<br />
liabilities, with $227,731 operating loss. This amount is an intercompany<br />
payable.<br />
The applicant provided audited financial <strong>state</strong>ments of its ultimate<br />
parent company and subsidiaries, Odyssey <strong>Health</strong>care, Inc., a <strong>for</strong>-profit<br />
corporation, <strong>for</strong> the periods ending December 31, 2008 and 2007. These<br />
<strong>state</strong>ments were analyzed <strong>for</strong> the purpose of evaluating the parent‟s<br />
ability to provide the capital and operational funding necessary to<br />
implement the project.<br />
Short-Term Position:<br />
The parent‟s current ratio of 1.7 indicates current assets are over oneand-a-half<br />
times the current obligations, this is slightly below average<br />
and an adequate position. The working capital of $82.4 million is a<br />
measure of excess liquidity that could be used to fund capital projects.<br />
The ratio of cash flow to current liabilities of 0.2 is well below average<br />
and a weak position. Overall, the parent has a slightly weak but<br />
adequate short-term position. (See Table below).<br />
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CON Action Number: 10061-10065<br />
Long-Term Position:<br />
The ratio of long-term debt to net assets of 0.7 is above average and<br />
indicates the parent may have difficulty obtaining additional debt<br />
financing if needed. The ratio of cash flow to assets of 4.6 percent is<br />
below average and a weak position. The most recent year had $30.8<br />
million in operating income, which resulted in a 5.0 percent operating<br />
margin. Overall, the applicant has a slightly weak but adequate longterm<br />
position. (See Table below).<br />
Odyssey <strong>Health</strong>care, Inc. and Subsidiaries<br />
107<br />
12/31/2008<br />
Current Assets (CA) $207,323,000<br />
Cash and Current Investment $56,043,000<br />
Total Assets (TA) $460,951,000<br />
Current Liabilities (CL) $124,894,000<br />
Total Liabilities (TL) $260,880,000<br />
Net Assets (NA) $200,071,000<br />
Total Revenues (TR) $616,050,000<br />
Interest Expense (IE) $7,430,000<br />
Operating Income (OI) $30,819,000<br />
Cash Flow from Operations (CFO) $21,049,000<br />
Working Capital $82,429,000<br />
FINANCIAL RATIOS<br />
12/31/2008<br />
Current Ratio (CA/CL) 1.7<br />
Cash Flow to Current Liabilities (CFO/CL) 0.2<br />
Long-Term Debt to Net Assets (TL-CL/NA) 0.7<br />
Times Interest Earned (OI+IE/IE) 5.1<br />
Net Assets to Total Assets (NA/TA) 43.4%<br />
Operating Margin (OI/TR) 5.0%<br />
Return on Assets (OI/TA) 6.7%<br />
12/31/2007<br />
$151,455,000<br />
$62,179,000<br />
$275,209,000<br />
$76,180,000<br />
$92,372,000<br />
$182,837,000<br />
$398,232,000<br />
$208,000<br />
$24,000,000<br />
$12,814,000<br />
$75,275,000<br />
12/31/2007<br />
2.0<br />
0.2<br />
0.1<br />
116.4<br />
66.4%<br />
6.0%<br />
8.7%<br />
Operating Cash Flow to Assets (CFO/TA) 4.6% 4.7%<br />
Capital Requirements:<br />
Schedule 2 indicates total capital projects of $1,906,825 which consist of<br />
the CON subject to this review, CON #10068 <strong>for</strong> a hospice in District 5B,<br />
and CON #10071 <strong>for</strong> a hospice in District 7B. The applicant is projecting<br />
a year one operating loss of $706,918. The applicant will have to fund<br />
the year one operating loss until profitability can be reached.
CON Action Numbers: 10061-10065<br />
Available Capital:<br />
Funding <strong>for</strong> this project will be provided by the parent. The parent has<br />
working capital of $82.4 million and $30.8 million in operating income.<br />
In addition, cash flow from operations was $21.0 million. The project<br />
would only represent 0.81 percent of the parent‟s working capital and<br />
3.17 percent of operating cash flows.<br />
Staffing:<br />
Schedule 6A indicates <strong>for</strong> year one ending December 31, 2011, the<br />
applicant <strong>for</strong>ecasts 17.7 FTEs as follows: administration, 7.1 FTEs;<br />
physicians, 0.1 FTEs; nursing, 4.2 FTEs; ancillary, 1.9 FTEs; dietary 0.1<br />
FTEs and social services, 0.8 FTEs. In the second year ending December<br />
31, 2012 the applicant <strong>for</strong>ecasts 25.0 FTEs as follows: administration,<br />
7.7 FTEs; physicians, 0.1 FTEs; nursing, 6.0 FTEs; ancillary, 2.6 FTEs;<br />
dietary 0.1 FTEs and social services, 0.8 FTEs.<br />
Conclusion:<br />
Funding <strong>for</strong> this project should be available as needed.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063): The financial<br />
impact of the project will include the project cost of $658,585 and<br />
incremental operating costs in year two of $7,658,900. The applicant is<br />
a Florida <strong>for</strong>-profit corporation and a development stage company that<br />
was <strong>for</strong>med on October 29, 2009 <strong>for</strong> the purpose of operating a hospice<br />
in Florida, with net assets of $1,050,000 and $10,000 in liabilities <strong>for</strong> the<br />
period ended November 30, 2009. The cash balance of $1,050,000<br />
represents the proceeds from issuing common stock. At the date of the<br />
audit, no operating results were available. Without results from<br />
operations, an analysis of the short and long-term strength of the<br />
applicant cannot be made.<br />
Capital Requirements:<br />
Schedule 2 indicates total capital projects of $658,585 which is the CON<br />
subject to this review. It should be noted that among the applicant‟s<br />
conditions, two conditions indentified a need <strong>for</strong> specific funds. Funding<br />
<strong>for</strong> those conditions is included in the capital budget on Schedule 2. In<br />
addition, the applicant will have to fund the projected year one operating<br />
loss of $355,500.<br />
Available Capital:<br />
The applicant provided audited financial <strong>state</strong>ments as of November 30,<br />
2009 showing $1,050,000 in cash with virtually no liabilities.<br />
108
CON Action Number: 10061-10065<br />
Staffing:<br />
Schedule 6A indicates <strong>for</strong> year one ending December 31, 2011, the<br />
applicant <strong>for</strong>ecasts 41.01 FTEs as follows: administration, 11.58 FTEs;<br />
physicians, 0.0 FTEs; nursing, 23.25 FTEs; ancillary, 0.0 FTEs; dietary<br />
0.75 FTEs and social services, 5.42 FTEs. In the second year ending<br />
December 31, 2012, the applicant <strong>for</strong>ecasts 62.85 FTEs as follows:<br />
administration, 17.0 FTEs; physicians, 0.0 FTEs; nursing, 36.76 FTEs;<br />
ancillary, 0.0 FTEs; dietary 1.17 FTEs and social services, 7.92 FTEs.<br />
Conclusion:<br />
Funding <strong>for</strong> the project should be available as needed.<br />
United Hospice of Florida, Inc. (CON #10064): The financial impact of<br />
the project will include the project cost of $251,233 and incremental<br />
operating costs in year two of $5,415,021. The applicant is a Florida <strong>for</strong>profit<br />
corporation, incorporated on October 16, 2009, <strong>for</strong> the purpose of<br />
operating a hospice and related businesses in the State of Florida. As of<br />
November 25, 2009, the applicant had $10,000 in assets and $9,000 in<br />
liabilities, with no operations.<br />
The applicant provided audited financial <strong>state</strong>ments of its ultimate<br />
parent company and subsidiaries, United <strong>Health</strong> Services, Inc., a <strong>for</strong>profit<br />
corporation, <strong>for</strong> the periods ending June 30, 2009 and 2008.<br />
These <strong>state</strong>ments were analyzed <strong>for</strong> the purpose of evaluating the<br />
parent‟s ability to provide the capital and operational funding necessary<br />
to implement the project.<br />
Short-Term Position:<br />
The parent‟s current ratio of 0.9 indicates current assets are less than<br />
current obligations. This is below average and a weak position. This<br />
results in a working capital deficit of $14.2 million. The ratio of cash<br />
flow to current liabilities of 0.4 is below average and a weak position.<br />
Overall, the parent has a weak short-term position. (See Table below).<br />
Long-Term Position:<br />
The ratio of long-term debt to net assets of 3.4 indicates the parent is<br />
highly leveraged and may have difficulty obtaining additional debt<br />
financing if needed. The ratio of cash flow to assets of 11.9 percent is<br />
well above average and a good position. The most recent year had $16.9<br />
million in operating income, which resulted in a 2.9 percent operating<br />
margin. Overall, the applicant has a slightly weak but adequate longterm<br />
position. (See Table below).<br />
109
CON Action Numbers: 10061-10065<br />
The weak short and long-term position of the parent appears to be the<br />
result of cash and debt used to make a number of health care facility<br />
acquisitions. The subsequent events note in the audit indicates that the<br />
parent entered into four additional health care facility acquisitions after<br />
the fiscal year end date.<br />
United <strong>Health</strong> Services, Inc. & Subsidiaries<br />
110<br />
6/30/2009<br />
Current Assets (CA) $81,073,997<br />
Cash and Current Investment $5,433,573<br />
Total Assets (TA) $333,743,323<br />
Current Liabilities (CL) $95,280,606<br />
Total Liabilities (TL) $279,042,673<br />
Net Assets (NA) $54,700,650<br />
Total Revenues (TR) $585,790,196<br />
Interest Expense (IE) $9,805,656<br />
Operating Income (OI) $16,927,485<br />
Cash Flow from Operations (CFO) $39,848,419<br />
Working Capital ($14,206,609)<br />
FINANCIAL RATIOS<br />
6/30/2009<br />
Current Ratio (CA/CL) 0.9<br />
Cash Flow to Current Liabilities (CFO/CL) 0.4<br />
Long-Term Debt to Net Assets (TL-CL/NA) 3.4<br />
Times Interest Earned (OI+IE/IE) 2.7<br />
Net Assets to Total Assets (NA/TA) 16.4%<br />
Operating Margin (OI/TR) 2.9%<br />
Return on Assets (OI/TA) 5.1%<br />
6/30/2008<br />
$80,304,743<br />
$2,609,207<br />
$285,565,941<br />
$85,137,811<br />
$244,469,013<br />
$41,096,928<br />
$518,137,965<br />
$11,139,539<br />
$12,512,127<br />
$21,188,644<br />
($4,833,068)<br />
6/30/2008<br />
0.9<br />
0.2<br />
3.9<br />
2.1<br />
14.4%<br />
2.4%<br />
4.4%<br />
Operating Cash Flow to Assets (CFO/TA) 11.9% 7.4%<br />
Capital Requirements:<br />
Schedule 2 indicates total capital projects of $532,595 which consist of<br />
the CON subject to this review and CON #10072 <strong>for</strong> a hospice in District<br />
7B. The applicant is projecting a year one operating loss of $438,171.<br />
The applicant will have to fund the year one operating loss until<br />
profitability can be reached.<br />
Available Capital:<br />
According to the application, the parent will fund this project through<br />
operating cash flows. The parent‟s audited financial <strong>state</strong>ments indicate<br />
cash flow from operations was $39.8 million. Although the parent shows
CON Action Number: 10061-10065<br />
weakness in both the short and long-term, this project, including<br />
funding the year one operating loss, would only represent 1.73 percent of<br />
operating cash flows.<br />
Staffing:<br />
Schedule 6A indicates <strong>for</strong> year one, the applicant <strong>for</strong>ecasts 16.97 FTEs<br />
as follows: administration, 17.5 FTEs; physicians, 0.0 FTEs (by contract);<br />
nursing, 7.14 FTEs; ancillary, 0.0 FTEs (by contract); dietary 1.0 FTEs<br />
and social services, 1.33 FTEs. In the second year, the applicant<br />
<strong>for</strong>ecasts 44.35 FTEs as follows: administration, 11.58 FTEs; physicians,<br />
0.0 FTEs (by contract); nursing, 28.59 FTEs; ancillary, 0.0 FTEs (by<br />
contract); dietary 1.0 FTEs and social services, 3.17 FTEs.<br />
Conclusion:<br />
Funding <strong>for</strong> the project should be available as needed.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065): The financial<br />
impact of the project will include the project cost of $338,353 and<br />
incremental operating costs in year two of $3,676,111.<br />
The <strong>Agency</strong> reviewed the audited financial <strong>state</strong>ments of the applicant (a<br />
Florida <strong>for</strong>-profit corporation) <strong>for</strong> the periods ending December 31, 2008<br />
and 2007. These <strong>state</strong>ments were analyzed <strong>for</strong> the purpose of evaluating<br />
the applicant‟s ability to provide the capital and operational funding<br />
necessary to implement the project.<br />
Short-Term Position:<br />
The applicant‟s current ratio of 2.0 indicates current assets are two times<br />
more than current obligations. This is slightly below average and an<br />
adequate position. The working capital of $18.5 million is a measure of<br />
excess liquidity that could be used to fund capital projects. The ratio of<br />
cash flow to current liabilities of 1.7 is well above average and a strong<br />
position. Overall, the applicant has good short-term position. (See Table<br />
below).<br />
Long-Term Position:<br />
The ratio of long-term debt to net assets of 0.4 is below average and<br />
indicates the applicant has sufficient equity to acquire additional debt if<br />
needed, a good position. The ratio of cash flow to assets of 16.2 percent<br />
is well above average and a good position. The most recent year had<br />
$48.5 million in operating income, which resulted in a 15.8 percent<br />
operating margin. Overall, the applicant has a good long-term position.<br />
(See Table below).<br />
111
CON Action Numbers: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida<br />
112<br />
12/31/2008<br />
Current Assets (CA) $37,834,884<br />
Cash and Current Investment $3,998<br />
Total Assets (TA) $198,385,855<br />
Current Liabilities (CL) $19,296,248<br />
Total Liabilities (TL) $69,602,225<br />
Net Assets (NA) $128,783,630<br />
Total Revenues (TR) $306,881,273<br />
Interest Expense (IE) $0<br />
Operating Income (OI) $48,463,815<br />
Cash Flow from Operations (CFO) $32,191,398<br />
Working Capital $18,538,636<br />
FINANCIAL RATIOS<br />
12/31/2008<br />
Current Ratio (CA/CL) 2.0<br />
Cash Flow to Current Liabilities (CFO/CL) 1.7<br />
Long-Term Debt to Net Assets (TL-CL/NA) 0.4<br />
Times Interest Earned (OI+IE/IE) #DIV/0!<br />
Net Assets to Total Assets (NA/TA) 64.9%<br />
Operating Margin (OI/TR) 15.8%<br />
Return on Assets (OI/TA) 24.4%<br />
12/31/2007<br />
$36,137,101<br />
$3,998<br />
$197,890,693<br />
$18,490,669<br />
$99,100,043<br />
$98,790,650<br />
$281,340,731<br />
$0<br />
$46,700,627<br />
$22,720,506<br />
$17,646,432<br />
12/31/2007<br />
2.0<br />
1.2<br />
0.8<br />
#DIV/0!<br />
49.9%<br />
16.6%<br />
23.6%<br />
Operating Cash Flow to Assets (CFO/TA) 16.2% 11.5%<br />
Capital Requirements:<br />
Schedule 2 indicates total capital projects of $4,838,353 which consist of<br />
the CON subject to this review and other capitalization. The applicant is<br />
projecting a year one operating loss of $457,514. The applicant will have<br />
to fund the year one operating loss until profitability can be reached.<br />
Available Capital:<br />
Schedule 2 indicates that funding <strong>for</strong> this project will be provided by the<br />
applicant‟s cash flows from operations. The applicant has working<br />
capital of $18.5 million and cash flow from operations of $32.2 million.<br />
The applicant listed several conditions in its application that included a<br />
financial impact in particular several charitable contributions totaling<br />
$850,000. It is not clear from the in<strong>for</strong>mation provided that these<br />
contributions were included in the capital cost or projected operations.<br />
However, it appears that the applicant has sufficient capital available to<br />
meet the charitable conditions proposed.
CON Action Number: 10061-10065<br />
Staffing:<br />
Schedule 6A indicates <strong>for</strong> year one, ending June 2011, the applicant<br />
<strong>for</strong>ecasts 17.49 FTEs as follows: administration, 4.65 FTEs; physicians,<br />
0.32 FTEs; nursing, 9.86 FTEs; ancillary, 0.0 FTEs (by contract); dietary<br />
0.0 FTEs (per assumptions a part of VITAS services) and social services,<br />
2.64 FTEs. In the second year, ending June 2012, the applicant<br />
<strong>for</strong>ecasts 39.08 FTEs as follows: administration, 7.9 FTEs; physicians,<br />
0.85 FTE); nursing, 26.6 FTEs; ancillary, 0.0 FTEs (by contract); dietary<br />
0.0 FTEs (per assumptions a part of VITAS services) 18 and social<br />
services, 3.71 FTEs.<br />
Conclusion:<br />
Funding <strong>for</strong> this project and the entire capital budget should be available<br />
as needed.<br />
d. What is the immediate and long-term financial feasibility of the<br />
proposal? ss. 408.035 (1)(f), Florida Statutes.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061): For year<br />
two of operations, the applicant projects Medicare at 85.0 percent,<br />
Medicaid at 4.7 percent, self-pay/charity at 1.9 percent, and commercial<br />
insurance at 8.3 percent.<br />
The applicant indicated on Schedule 7 that it intends to provide routine<br />
home care, continuous home care, inpatient respite, and general<br />
inpatient care, and <strong>for</strong> which the Department of <strong>Health</strong> and Human<br />
Services sets rates. The federal rates were calculated <strong>for</strong> the Duval<br />
County, Florida Wage Index <strong>for</strong> Medicare Hospice payments of 0.9499<br />
and inflated through June 2012. The average price adjustment factor<br />
used was 2.8 percent per year based on the new CMS Market Basket<br />
Price Index as published in the 1st Quarter 2009 <strong>Health</strong> <strong>Care</strong> Cost<br />
Review.<br />
Estimated patient days <strong>for</strong> each level of service from Schedule 7, year two<br />
were multiplied by the calculated reimbursement rate <strong>for</strong> that service in<br />
order to estimate the total revenue that would be generated by that<br />
number of patient days. The results were then compared to the<br />
applicant‟s estimated gross revenue. The results of the calculations are<br />
summarized in the Table below.<br />
18 CON Application #10065, Schedule 6A - Summary of Significant Assumptions indicates that VITAS<br />
uses certified staff dieticians as needed.<br />
113
CON Action Numbers: 10061-10065<br />
The applicant calculated continuous care revenues based on 16 hours of<br />
care rather than 24 hours. The applicant indicated that due to death or<br />
other causes, some patients will not, however, receive 24 hours of<br />
continuous care and will not, there<strong>for</strong>e, be eligible <strong>for</strong> reimbursement <strong>for</strong><br />
a given day. In <strong>Agency</strong> calculation, staff made the same adjustment of a<br />
partial 16 hour payment. Based on <strong>Agency</strong> calculation, the applicant‟s<br />
projected gross revenue was -3.42 percent, or $164,792, less than the<br />
calculated gross revenue. The difference is primarily the result of<br />
contractual adjustments and is there<strong>for</strong>e, not considered material.<br />
Operating profits from this project are expected to increase from a loss of<br />
$330,083 <strong>for</strong> year one to a profit of $286,993 <strong>for</strong> year two.<br />
Conclusion:<br />
This project appears to be financially feasible.<br />
HOSPICE REVENUE TABLE<br />
CON #10061 Compassionate <strong>Care</strong> Hospice of Florida, Inc.<br />
Wage Index <strong>for</strong> Duval County(.9499)<br />
Wage<br />
Component Wage Index<br />
114<br />
Adjusted<br />
Wage<br />
Amount<br />
Unadjusted<br />
Component<br />
Payment<br />
Rate<br />
Routine Home <strong>Care</strong> $98.19 0.9499 $93.27 $44.72 $137.99<br />
Continuous Home <strong>Care</strong> $573.11 0.9499 $544.40 $260.99 $536.92**<br />
Inpatient Respite $80.02 0.9499 $76.01 $67.81 $143.82<br />
General Inpatient $406.94 0.9499 $386.55 $228.80 $615.35<br />
Payment<br />
Rate<br />
Inflation<br />
Factor Year<br />
Two<br />
Inflation<br />
Adjusted<br />
Amount<br />
Patient<br />
Days, June<br />
Year Two -<br />
2012<br />
Calculated<br />
Gross<br />
Revenue<br />
Routine Home <strong>Care</strong> $137.99 1.049 $144.74 30,685 $4,441,210<br />
Continuous Home <strong>Care</strong> $536.92 1.049 $563.17 491 $276,516<br />
Inpatient Respite $143.82 1.049 $150.85 39 $5,883<br />
General Inpatient $615.35 1.049 $645.43 407 $262,690<br />
Total 31,622 $4,986,300<br />
From Schedule 7 $4,821,508<br />
Difference<br />
-$164,792<br />
Percentage difference -3.42%<br />
** Continuous Home <strong>Care</strong> is calculated based on 16 hours of care rather than 24 hours.
CON Action Number: 10061-10065<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062): For year two of<br />
operations, the applicant projects Medicare at 93.0 percent, Medicaid at<br />
3.0 percent, self-pay/charity at 2.0 percent, and managed<br />
care/commercial insurance at 2.0 percent.<br />
The applicant indicated on Schedule 7 that the service it intends to<br />
provide is routine home care, continuous home care, general inpatient<br />
care, and inpatient respite, and <strong>for</strong> which the Department of <strong>Health</strong> and<br />
Human Services sets rates. The federal rates were calculated <strong>for</strong> the<br />
Duval County, Florida Wage Index <strong>for</strong> Medicare Hospice payments of<br />
0.9499 and inflated through December 2012. The average price<br />
adjustment factor used was 2.9 percent per year based on the new CMS<br />
Market Basket Price Index as published in the 1st Quarter 2009 <strong>Health</strong><br />
<strong>Care</strong> Cost Review.<br />
Estimated patient days <strong>for</strong> each level of service from Schedule 7, year two<br />
were multiplied by the calculated reimbursement rate <strong>for</strong> that service in<br />
order to estimate the total revenue that would be generated by that<br />
number of patient days. The results were then compared to the<br />
applicant‟s estimated gross revenue. The results of the calculations are<br />
summarized in the Table below.<br />
The applicant offered 26 conditions to its proposed hospice program.<br />
Several of these conditions would likely have a financial impact on the<br />
applicant. Based on the notes accompanying the projections, it appears<br />
that the applicant has taken into consideration the costs associated with<br />
the proposed conditions in the financial projections.<br />
The applicant‟s projected gross revenue was 3.39 percent, or $96,149,<br />
slightly less than the calculated gross revenue. The applicant used a<br />
lower inflation rate (2.0 percent) which is a conservative assumption.<br />
When the difference in inflation rates are considered, the difference in<br />
revenue projected is not deemed material. Operating profits from this<br />
project are expected to increase from a loss of $706,918 <strong>for</strong> year one to a<br />
profit of $78,063 <strong>for</strong> year two.<br />
Conclusion:<br />
This project appears to be financially feasible.<br />
115
HOSPICE REVENUE TABLE<br />
CON #10062 Odyssey <strong>Health</strong>care of Collier County, Inc.<br />
Wage Index <strong>for</strong> Duval County(.9499)<br />
CON Action Numbers: 10061-10065<br />
Wage<br />
Component Wage Index<br />
116<br />
Adjusted<br />
Wage<br />
Amount<br />
Unadjusted<br />
Component<br />
Payment<br />
Rate<br />
Routine Home <strong>Care</strong> $98.19 0.9499 $93.27 $44.72 $137.99<br />
Continuous Home <strong>Care</strong> $573.11 0.9499 $544.40 $260.99 $805.39<br />
Inpatient Respite $80.02 0.9499 $76.01 $67.81 $143.82<br />
General Inpatient $406.94 0.9499 $386.55 $228.80 $615.35<br />
Payment<br />
Rate<br />
Inflation<br />
Factor Year<br />
Two<br />
Inflation<br />
Adjusted<br />
Amount<br />
Patient Days<br />
Year Two,<br />
December<br />
31 -2012<br />
Calculated<br />
Gross<br />
Revenue<br />
Routine Home <strong>Care</strong> $137.99 1.064 $146.80 16,269 $2,388,358<br />
Continuous Home <strong>Care</strong> $805.39 1.064 $856.83 341 $292,178<br />
Inpatient Respite $143.82 1.064 $153.01 172 $26,317<br />
General Inpatient $615.35 1.064 $654.66 341 $223,237<br />
Total 17,123 $2,930,091<br />
From Schedule 7 $2,833,942<br />
Difference<br />
-$96,149<br />
Percentage difference -3.39%<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063): For year two of<br />
operations, the applicant projects Medicare at 88.0 percent, Medicaid at<br />
4.0 percent, self-pay/charity at 0.5 percent, and commercial insurance<br />
and other payers at 7.5 percent.<br />
The applicant indicated on Schedule 7 that the service it intends to<br />
provide is routine home care, continuous home care, inpatient respite,<br />
and general inpatient care, and <strong>for</strong> which the Department of <strong>Health</strong> and<br />
Human Services sets rates. The federal rates were calculated <strong>for</strong> the<br />
Duval County, Florida Wage Index <strong>for</strong> Medicare Hospice payments of<br />
0.9499 and inflated through June 2012. The average price adjustment<br />
factor used was 2.8 percent per year based on the new CMS Market<br />
Basket Price Index as published in the 1st Quarter 2009 <strong>Health</strong> <strong>Care</strong><br />
Cost Review.<br />
The applicant did not provide a table with patient days by level of care<br />
(routine home, continuous home, inpatient respite, and general inpatient<br />
care). There<strong>for</strong>e, estimated revenues <strong>for</strong> each level of service from<br />
Schedule 7, year two were divided by the calculated reimbursement rate
CON Action Number: 10061-10065<br />
<strong>for</strong> that service in order to estimate the total patient days that would be<br />
generated by that level of revenue. The results were then compared to<br />
the applicant‟s estimated number of patient days. The results of the<br />
calculations are summarized in the Table below.<br />
The applicant‟s projected patient days were 2.7 percent or 938 days more<br />
than the calculated patient days. The applicant indicated using a 2.0<br />
percent inflation rate. If the <strong>Agency</strong> uses the same inflation rate as the<br />
applicant, the difference in calculated days is immaterial. Operating<br />
profits from this project are expected to increase from an operating loss<br />
of $355,500 <strong>for</strong> year one to an operating profit of $496,300 <strong>for</strong> year two.<br />
Conclusion: This project appears to be financially feasible.<br />
HOSPICE REVENUE TABLE<br />
CON #10063 Seasons Palliative <strong>Care</strong> of Florida, Inc.<br />
Wage Index <strong>for</strong> Duval County(.9499)<br />
Wage<br />
Component Wage Index<br />
117<br />
Adjusted<br />
Wage<br />
Amount<br />
Unadjusted<br />
Component<br />
Payment<br />
Rate<br />
Routine Home <strong>Care</strong> $98.19 0.9499 $93.27 $44.72 $137.99<br />
Continuous Home <strong>Care</strong> $573.11 0.9499 $544.40 $260.99 $805.39<br />
Inpatient Respite $80.02 0.9499 $76.01 $67.81 $143.82<br />
General Inpatient $406.94 0.9499 $386.55 $228.80 $615.35<br />
Payment<br />
Rate<br />
Inflation<br />
Factor Year<br />
Two<br />
Inflation<br />
Adjusted<br />
Amount<br />
Gross<br />
Revenue<br />
Year Two,<br />
Dec-2011*<br />
Calculated<br />
Medicare<br />
Patient<br />
Days<br />
Routine Home <strong>Care</strong> $137.99 1.064 $146.80 $4,718,600 32,142<br />
Continuous Home <strong>Care</strong> $805.39 1.064 $856.83 $202,300 236<br />
Inpatient Respite $143.82 1.064 $153.01 $6,200 41<br />
General Inpatient $615.35 1.064 $654.66 $784,000 1,198<br />
Total $5,711,100 33,616<br />
From Schedule 7 34,554<br />
Difference<br />
938<br />
Percentage difference 2.71%
CON Action Numbers: 10061-10065<br />
United Hospice of Florida, Inc. (CON #10064): For year two of<br />
operations, the applicant projects Medicare at 92.5 percent, Medicaid at<br />
5.0 percent, charity at 1.0 percent, and commercial insurance at 1.5<br />
percent.<br />
The applicant indicated on Schedule 7 that the service it intends to<br />
provide is routine home care, continuous home care, general inpatient<br />
care, and inpatient respite, and <strong>for</strong> which the Department of <strong>Health</strong> and<br />
Human Services sets rates. The federal rates were calculated <strong>for</strong> the<br />
Duval County, Florida Wage Index <strong>for</strong> Medicare Hospice payments of<br />
0.9499 and inflated through June 2012. The average price adjustment<br />
factor used was 2.8 percent per year based on the new CMS Market<br />
Basket Price Index as published in the 1st Quarter 2009 <strong>Health</strong> <strong>Care</strong><br />
Cost Review.<br />
Estimated patient days <strong>for</strong> each level of service from Schedule 7, year two<br />
were multiplied by the calculated reimbursement rate <strong>for</strong> that service in<br />
order to estimate the total revenue that would be generated by that<br />
number of patient days. The results were then compared to the<br />
applicant‟s estimated gross revenue. The results of the calculations are<br />
summarized in the Table below.<br />
The applicant calculated continuous care revenues based on 16 hours of<br />
care rather than 24 hours. The applicant indicated that due to death or<br />
other causes, some patients will not, however, receive 24 hours of<br />
continuous care and will not, there<strong>for</strong>e, be eligible <strong>for</strong> reimbursement <strong>for</strong><br />
a given day. In our calculation, we made the same adjustment of a<br />
partial 16-hour payment. Based on the <strong>Agency</strong>‟s calculation, the<br />
applicant‟s projected gross revenue was 2.78 percent, or $151,394, less<br />
than the calculated gross revenue. Understating revenue is a<br />
conservative assumption and there<strong>for</strong>e reasonable. Operating profits<br />
from this project are expected to increase from a loss of $438,171 <strong>for</strong><br />
year one to a profit of $598,144 <strong>for</strong> year two.<br />
Conclusion: This project appears to be financially feasible.<br />
118
HOSPICE REVENUE TABLE<br />
CON #10064 United Hospice of Florida, Inc.<br />
Wage Index <strong>for</strong> Duval County(.9499)<br />
CON Action Number: 10061-10065<br />
Wage<br />
Component Wage Index<br />
119<br />
Adjusted<br />
Wage<br />
Amount<br />
Unadjusted<br />
Component<br />
Payment<br />
Rate<br />
Routine Home <strong>Care</strong> $98.19 0.9499 $93.27 $44.72 $137.99<br />
Continuous Home <strong>Care</strong> $573.11 0.9499 $544.40 $260.99 $536.92**<br />
Inpatient Respite $80.02 0.9499 $76.01 $67.81 $143.82<br />
General Inpatient $406.94 0.9499 $386.55 $228.80 $615.35<br />
Payment<br />
Rate<br />
Inflation<br />
Factor Year<br />
Two<br />
Inflation<br />
Adjusted<br />
Amount<br />
Patient Days<br />
Year Two,<br />
December 31<br />
-2012<br />
Calculated<br />
Gross<br />
Revenue<br />
Routine Home <strong>Care</strong> $137.99 1.049 $144.74 31,990 $4,630,090<br />
Continuous Home <strong>Care</strong> $536.92 1.049 $563.17 846 $476,441<br />
Inpatient Respite $143.82 1.049 $150.85 339 $51,138<br />
General Inpatient $615.35 1.049 $645.43 677 $436,956<br />
Total 33,852 $5,594,626<br />
From Schedule 7 $5,443,232<br />
Difference<br />
** Continuous Home <strong>Care</strong> is calculated based on 16 hours of care rather than 24 hours.<br />
-$151,394<br />
Percentage difference -2.78%<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065): For year two<br />
of operations, the applicant projects Medicare at 92.0 percent, Medicaid<br />
at 5.0 percent, charity at 1.0 percent, and commercial insurance at 2.0<br />
percent.<br />
The applicant indicated on Schedule 7 that the service it intends to<br />
provide is routine home care, continuous home care, general inpatient<br />
care, and inpatient respite, and <strong>for</strong> which the Department of <strong>Health</strong> and<br />
Human Services sets rates. The federal rates were calculated <strong>for</strong> the<br />
Duval County, Florida Wage Index <strong>for</strong> Medicare Hospice payments of<br />
0.9499 and inflated through June 2012. The average price adjustment<br />
factor used was 2.8 percent per year based on the new CMS Market<br />
Basket Price Index as published in the 1st Quarter 2009 <strong>Health</strong> <strong>Care</strong><br />
Cost Review.
CON Action Numbers: 10061-10065<br />
Estimated patient days <strong>for</strong> each level of service from Schedule 7, year two<br />
were multiplied by the calculated reimbursement rate <strong>for</strong> that service in<br />
order to estimate the total revenue that would be generated by that<br />
number of patient days. The results were then compared to the<br />
applicant‟s estimated gross revenue. The results of the calculations are<br />
summarized in the Table below.<br />
The applicant calculated continuous care revenues based on 15.5 hours<br />
of care rather than 24 hours. Due to death or other causes, some<br />
patients will not receive 24 hours of continuous care and will not,<br />
there<strong>for</strong>e, be eligible <strong>for</strong> full reimbursement <strong>for</strong> a given day. In the<br />
<strong>Agency</strong>‟s calculation, staff made the same adjustment of a partial 15.5<br />
hour payment. Based on <strong>Agency</strong> calculation, the applicant‟s projected<br />
gross revenue was -2.26 percent, or $84,492, less than the calculated<br />
gross revenue. Some of this difference is due to the applicant using a<br />
lower rate of inflation than 2.8 percent rate used in our analysis. Using<br />
a lower inflation rate is a conservative assumption and there<strong>for</strong>e<br />
reasonable. It should be noted that the applicant included Inpatient<br />
Respite days with Routine Home <strong>Care</strong> days. Inpatient Respite is typically<br />
a relatively low volume activity <strong>for</strong> a Hospice and the difference in<br />
reimbursement rates is relatively small. Operating profits from this<br />
project are expected to increase from a loss of $457,514 <strong>for</strong> year one to a<br />
profit of $28,692 <strong>for</strong> year two.<br />
Conclusion: This project appears to be financially feasible.<br />
120
HOSPICE REVENUE TABLE<br />
CON #10065 VITAS <strong>Health</strong>care Corporation of Florida<br />
Wage Index <strong>for</strong> Duval County(.9499)<br />
CON Action Number: 10061-10065<br />
Wage<br />
Component Wage Index<br />
121<br />
Adjusted<br />
Wage<br />
Amount<br />
Unadjusted<br />
Component<br />
Payment<br />
Rate<br />
Routine Home <strong>Care</strong> $98.19 0.9499 $93.27 $44.72 $137.99<br />
Continuous Home <strong>Care</strong> $573.11 0.9499 $544.40 $260.99 $520.15**<br />
Inpatient Respite $80.02 0.9499 $76.01 $67.81 $143.82<br />
General Inpatient $406.94 0.9499 $386.55 $228.80 $615.35<br />
Payment<br />
Rate<br />
Inflation<br />
Factor Year<br />
Two<br />
Inflation<br />
Adjusted<br />
Amount<br />
Patient Days<br />
Year Two,<br />
June 11 -<br />
2012<br />
Calculated<br />
Gross<br />
Revenue<br />
Routine Home <strong>Care</strong> $137.99 1.049 $144.74 20,107 $2,910,198<br />
Continuous Home <strong>Care</strong> $520.15 1.049 $545.57 866 $472,464<br />
Inpatient Respite $143.82 1.049 $150.85 0 $0<br />
General Inpatient $615.35 1.049 $645.43 688 $444,056<br />
Total 21,661 $3,826,717<br />
From Schedule 7 $3,742,225<br />
Difference<br />
-$84,492<br />
Percentage difference -2.26%<br />
** Continuous Home <strong>Care</strong> is calculated based on 15.5 hours of care rather than 24 hours.<br />
e. Will the proposed project foster competition to promote quality and<br />
cost-effectiveness? ss. 408.035(1)(e) and (g), Florida Statutes.<br />
Each co-batched applicant is applying <strong>for</strong> a new hospice program to be<br />
located in Hospice Service Area 4A that currently has three existing<br />
hospice programs. There<strong>for</strong>e, each co-batched applicant is offering a<br />
new choice of provider in the hospice service area.<br />
The impact of the price of services on consumer choice is limited to the<br />
payer type. Most consumers do not pay directly <strong>for</strong> hospice services<br />
rather they are covered by a third-party payer. The impact of price<br />
competition would be limited to third-party payers that negotiate price<br />
<strong>for</strong> services, namely managed care organizations. There<strong>for</strong>e, price<br />
competition is limited to the share of patient days that are under<br />
managed care plans.
CON Action Numbers: 10061-10065<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061): The<br />
applicant is projecting 8.3 percent of its patient days from managed<br />
care/commercial insurance payers with 89.7 percent of patient days<br />
expected to come from fixed price government payer sources (Medicare<br />
and Medicaid), with the remaining 1.9 percent as self-pay/charity.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida/CON #10062 (Odyssey or OHCCF):<br />
The applicant is projecting 2.0 percent of its patient days from managed<br />
care/commercial insurance payers with 96.0 percent of patient days<br />
expected to come from fixed price government payer sources (Medicare<br />
and Medicaid).<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063): The applicant<br />
is projecting 5.0 percent of its patient days from managed<br />
care/commercial insurance payers with 92.0 percent of patient days<br />
expected to come from fixed price government payer sources (Medicare<br />
and Medicaid), with the remaining 0.5 percent as self-pay/charity.<br />
United Hospice of Florida, Inc. (CON #10064): The applicant is<br />
projecting 1.5 percent of its patient days from managed care/commercial<br />
insurance payers with 97.5 percent of patient days expected to come<br />
from fixed price government payer sources (Medicare and Medicaid).<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065): The<br />
applicant is projecting 2.0 percent of its patient days from commercial<br />
insurance payers with 97.0 percent of patient days expected to come<br />
from fixed price government payer sources (Medicare and Medicaid).<br />
ALL Projects: With the large majority of patient care being provided<br />
from fixed-price government payer sources, this project is not likely to<br />
have any discernable positive impact on price-based competition to<br />
promote cost-effectiveness. As providers offer new or enhanced services<br />
to patients and families as a means to compete on quality measures,<br />
cost-effectiveness would be impacted since the new or enhanced services<br />
would be offered despite the large percentage of fixed-priced government<br />
payers. In other words, the potential exists <strong>for</strong> new or enhanced services<br />
to be provided <strong>for</strong> the same federal and <strong>state</strong> dollars.<br />
Conclusion <strong>for</strong> all projects: The applicant‟s project is not likely to<br />
result in price-based competition.<br />
122
CON Action Number: 10061-10065<br />
f. Are the proposed costs and methods of construction reasonable? Do<br />
they comply with statutory and rule requirements?<br />
ss. 408.035(1)(h), Florida Statutes and Ch. 59A-3 or 59A-4, Florida<br />
Administrative Code.<br />
There are no inpatient construction facility costs or methods associated<br />
with the proposals.<br />
g. Does the applicant have a history of providing health services to<br />
Medicaid patients and the medically indigent? Does the applicant<br />
propose to provide health services to Medicaid patients and the<br />
medically indigent? ss. 408.035(1)(i), Florida Statutes.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) <strong>state</strong>s<br />
that it has a history of providing health services to Medicaid patients and<br />
the medically indigent. According to the applicant, in 2009, its programs<br />
collectively provided 23,459 Medicaid days representing 3.5 percent of<br />
total patient days and 17,300 days to self-pay and uncollectible patients,<br />
representing 2.6 percent of total days.<br />
Schedule 7A shows Medicaid is projected at five percent of year one and<br />
4.7 percent of year two patient days. The applicant projects $145,188 <strong>for</strong><br />
charity/self-pay (uncompensated) care in year one, and $102,810 <strong>for</strong><br />
charity care year two. Self-pay (uncompensated) care will account <strong>for</strong> 5.1<br />
percent of total patient days <strong>for</strong> year one and 1.9 percent of total patient<br />
days <strong>for</strong> year two (860 patient days and 613 patient days, respectively).<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) <strong>state</strong>s that in fiscal year<br />
2008, approximately 55 percent of the parent‟s (Odyssey <strong>Health</strong><strong>Care</strong>,<br />
Inc.‟s) non-Medicare net revenue was Medicaid and approximately 9.5<br />
percent of non-Medicare services was provided to indigent/charity<br />
patients. The applicant stresses that it conditions that it will provide<br />
care to all eligible patients without regard to their ability to pay. As<br />
<strong>state</strong>d previously, hospice programs are required by federal and <strong>state</strong> law<br />
to provide hospice services to everyone requesting them regardless of<br />
their ability to pay and there<strong>for</strong>e the <strong>Agency</strong> would not place conditions<br />
on a program to provide legally required services.<br />
123
CON Action Numbers: 10061-10065<br />
Schedule 7A shows Medicaid is projected at three percent of year one<br />
and year two patient days. The applicant projects $27,823 <strong>for</strong><br />
charity/self-pay care in year one, and $78,101 in year two. According to<br />
the schedule notes, charity care is reflected in the self-pay column and is<br />
<strong>for</strong>ecasted at 2.0 percent of patient days <strong>for</strong> both year one and year two<br />
(123 patient days and 342 patient days, respectively).<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) indicates that<br />
<strong>for</strong> the 12-month period ending October 2009, 1.9 percent of Season‟s<br />
hospice patients were Medicaid patients and 1.7 percent were nonfunded.<br />
Schedule 7A shows Medicaid is projected at four percent of year one and<br />
year two patient days. The applicant projects $0.00 <strong>for</strong> charity/self-pay<br />
care in year one, and $0.00 <strong>for</strong> charity care year two. However, the<br />
schedule estimates charity/other payers at $66,900 in year one and<br />
$143,600 <strong>for</strong> charity/other payers year two. According to the schedule‟s<br />
notes, charity care has been recorded as “Other Payers”. According to<br />
the schedule notes, charity care is reflected in the self-pay column and is<br />
<strong>for</strong>ecasted at 0.5 percent of patient days <strong>for</strong> both year one and year two<br />
(82 patient days and 173 patient days, respectively).<br />
United Hospice of Florida, Inc. (CON #10064) indicates that the<br />
parent, United <strong>Health</strong> Services, Inc., provided over 10 percent of its<br />
patient days to Medicaid and indigent care over the three year period<br />
ending October 31, 2009. According to the applicant, the parent‟s<br />
Medicaid as percent of total patient days has ranged from as high as 10.0<br />
percent (2008) to as low as 8.6 percent (2009). Likewise, the parent is<br />
<strong>state</strong>d to have had an indigent rate as high as 1.2 percent (2007) to as<br />
low as 0.4 percent (2009).<br />
Schedule 7A shows Medicaid is projected at five percent of year one and<br />
year two patient days. The applicant projects $13,803 <strong>for</strong> charity care in<br />
year one, and $54,450 <strong>for</strong> year two. For both year one and two, the<br />
applicant <strong>for</strong>ecasts 1.0 percent of patient days to charity care (99 patient<br />
days and 339 patient days, respectively).<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) <strong>state</strong>s that<br />
“year after year” VITAS provides 1.0 percent or more of revenues in<br />
charity care and that <strong>for</strong> fiscal year 2008, this amount exceeded $9.1<br />
Million.<br />
Schedule 7A shows Medicaid is projected at 4.7 percent of year one and<br />
five percent of year two patient days. The applicant projects $82,286 <strong>for</strong><br />
charity care in year one, and $37,422 <strong>for</strong> charity care year two. The<br />
124
CON Action Number: 10061-10065<br />
schedule further <strong>for</strong>ecasts 6.9 percent of patient days <strong>for</strong> year one and<br />
1.0 percent of patient days <strong>for</strong> year two to be <strong>for</strong> charity patients (519<br />
patient days and 217 patient days, respectively).<br />
F. SUMMARY<br />
In Volume 35, Number 39 of the Florida Administrative Weekly, dated<br />
October 2, 2009, the <strong>Agency</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong> <strong>Administration</strong> published a<br />
need <strong>for</strong> one hospice program in Hospice Service Area 4A (Baker, Clay,<br />
Duval, Nassau, and St. Johns Counties) <strong>for</strong> the January 2011 Hospice<br />
Planning Horizon.<br />
All five co-batched applicants propose the establishment of a new<br />
hospice program in Hospice Service Area 4A, consisting of Baker, Clay,<br />
Duval, Nassau, and St. Johns Counties.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061): The<br />
proposed total project cost is $227,616 with year one operating costs of<br />
$2,609,608 and year two costs of $4,236,244.<br />
Compassionate <strong>Care</strong> proposes a nine general conditions list with eight<br />
specific conditions.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062): The proposed total<br />
project cost is $666,972 with year one operating costs of $1,678,931 and<br />
year two costs of $2,650,443.<br />
Odyssey proposes 26 conditions.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063): The proposed<br />
total project cost is $658,585 with year one operating costs of<br />
$4,165,000 and year two costs of $7,658,900.<br />
Seasons proposes 20 conditions.<br />
United Hospice of Florida, Inc. (CON #10064): The proposed total<br />
project cost is $251,233 with year one operating costs of $1,975,427 and<br />
year two costs of $5,415,021.<br />
United proposes one general condition and 10 specific conditions.<br />
125
CON Action Numbers: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065): The<br />
proposed total project cost is $338,353 with year one operating costs of<br />
$1,575,144 and year two costs of $3,676,111.<br />
VITAS proposes one general condition and three primary conditions that<br />
are each, in turn, bulleted.<br />
Need/Access:<br />
Each co-batched applicant is responding to published need <strong>for</strong> an<br />
additional hospice program <strong>for</strong> the January 2011 Hospice Planning<br />
Horizon and each applicant discusses populations it believes to be<br />
experiencing unmet need.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061) <strong>state</strong>s<br />
need and access in the context of the following: all ages in all diagnostic<br />
groups lack hospice access; non-cancer patients age 65 and older lack<br />
hospice access and geographic and rural challenges in the area overall<br />
negatively impact hospice care there. The applicant <strong>report</strong>s a <strong>state</strong>wide<br />
hospice penetration <strong>for</strong> non-cancer patients age 65 or older greater than<br />
like penetration in hospice service area and offers this as support of need<br />
<strong>for</strong> this population group.<br />
This applicant <strong>state</strong>s that it sent an extensive community assessment<br />
questionnaire to 242 area providers (hospitals, nursing homes, assisted<br />
living facilities, end-stage renal disease centers, adult day care and adult<br />
family care centers). The applicant <strong>report</strong>s about a four percent response<br />
rate and that the primary feedback was as follows: no specific unmet<br />
need was identified, there was need <strong>for</strong> support services to staff in<br />
nursing homes after the loss of a long-term resident, unclear causes were<br />
leading to patients needing IV pain medication, and the applicant was<br />
welcomed into the local hospice market. The applicant emphasizes that<br />
according to its survey and all related assessment ef<strong>for</strong>ts regarding this<br />
project, no one responder identified a specific programmatic need.<br />
Compassionate <strong>Care</strong> had the fewest letters of support of any of cobatched<br />
applicant and none by any of the non-health care constituency<br />
groups the applicant <strong>state</strong>s to be in need of a new/additional hospice<br />
program in the area.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062) <strong>state</strong>s not only the<br />
<strong>Agency</strong>-defined need but also <strong>state</strong>s that there are “special and not<br />
normal” circumstances to warrant a new hospice program in the area.<br />
126
CON Action Number: 10061-10065<br />
The applicant <strong>state</strong>s that utilization rates in the area show consistent<br />
unmet need when compared to <strong>state</strong>wide averages <strong>for</strong> cancer patients<br />
aged 65 years and older; non-cancer patients aged 65 years and older<br />
and non-cancer patients under age 65.<br />
Odyssey presents a Hospice Service Area 4A profile, with demographic<br />
data including major causes of death, three-year age adjusted mortality<br />
data, county death data and limitation of existing hospice providers in<br />
the area. Second, the applicant presents a discussion of the rationale<br />
behind the project, with an explanation of the applicant‟s quality and<br />
experience. This second point is highlighted by what the applicant<br />
references as its <strong>Care</strong>Beyond Program - specialized hospice protocols<br />
unique to specific diseases including cancer, COPD, congestive heart<br />
failure and dementia. Third, the applicant presents a quantitative need<br />
argument and a market <strong>for</strong>ecast. Odyssey discusses need in terms of the<br />
<strong>Agency</strong>‟s need projection, <strong>Agency</strong>‟s need projection modified to include<br />
the service area‟s higher provision compared to the <strong>state</strong> average of<br />
service to cancer patients under age 65 and historical growth rates.<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) <strong>report</strong>ed senior<br />
executive staff of Seasons visited the local area on two occasions and<br />
spent several days assessing the hospice need. The applicant<br />
concentrated its need determination in the second largest population<br />
area in the hospice service area – Clay County. Seasons finds the<br />
hospice population with greatest unmet need to be cancer patients age<br />
65 and older and non-cancer patients age 65 and older and uses<br />
statistical data to reach this conclusion. However, this applicant does<br />
not offer a particular homeless, minority (African American) or rural<br />
focus as experiencing particular unmet hospice need and is second only<br />
to Compassionate <strong>Care</strong> (CON #10061) in having the fewest letters of local<br />
support to identify need.<br />
United Hospice of Florida, Inc. (CON #10064) identified the following<br />
four populations as experiencing hospice under service: minorities<br />
(African Americans); the homeless; non-cancer patients (of all ages but<br />
particularly the elderly ages 65 and older) and rural residents<br />
(particularly in Baker County and to some extent rural Nassau County).<br />
The applicant supports its conclusions that these groups are in greatest<br />
hospice need in several ways. The applicant provides published articles<br />
that nationwide, minorities (the African American population in<br />
particular) lack adequate hospice care and local data that in 2008, local<br />
hospitals were discharging African Americans to local hospices at a<br />
disproportionately lower rate compared to like discharges among all<br />
other hospice patients. United provides a detailed explanation of its<br />
outreach ef<strong>for</strong>ts and has been successful in doing so in other venues<br />
127
CON Action Numbers: 10061-10065<br />
(such as in Atlanta Georgia) and names specific local African American<br />
groups it intends to reach. However, the applicant did not have support<br />
letters from any of these groups.<br />
United provides a good description of the service area‟s homeless<br />
population and letters of support from five homeless organizations<br />
including the Emergency Services and Homeless Coalition of<br />
Jacksonville, Inc., The Medical Home <strong>for</strong> Homeless Children Project, the<br />
I.M. Sulzbacher Center <strong>for</strong> the Homeless, Family Promise of Jacksonville<br />
and Presbyterian Social Ministries, Inc.<br />
With regard to rural concerns, United Hospice is the only co-batched<br />
applicant to reference that Baker County is within the St. Johns River<br />
Rural <strong>Health</strong> Network and is a designated <strong>Health</strong> Professional Shortage<br />
Area and Medically Underserved Area as declared by the Shortage<br />
Designation Branch, Bureau of <strong>Health</strong> Professions, <strong>Health</strong> Resources<br />
and Services <strong>Administration</strong>, US Department of <strong>Health</strong> and Human<br />
Services. There are support letters from Baker County to support the<br />
project and the applicant <strong>state</strong>s it is well suited to reach rural areas<br />
based on its <strong>state</strong>d experience in other similar rural venues in other<br />
<strong>state</strong>s in which United operates hospice programs (Georgia, North<br />
Carolina and South Carolina). As <strong>for</strong> terminally ill non-cancer patients,<br />
the applicant <strong>report</strong>s that <strong>for</strong> the 12-month period ending October 31,<br />
2009, 73.3 percent of all admissions to the 25 United Hospice programs<br />
across the southeast region in which it operates were non-cancer<br />
diagnoses and as high as 87.5 percent in some programs. According to<br />
United its <strong>Care</strong>Beyond Program, in which disease-specific hospice care is<br />
applied to applicable patients, depending on the particular diagnosis<br />
would be a hallmark to serve this population.<br />
As part of its in-depth marketing field survey and analysis ef<strong>for</strong>ts, the<br />
applicant <strong>state</strong>s that United Hospice conducted a town hall meeting at<br />
the Crown Plaza Hotel in Jacksonville (Duval County), on December 15,<br />
2009 and that this was published by a widely circulated local newspaper<br />
(The Florida Times-Union) <strong>for</strong> three consecutive days. United has the<br />
second most letters of commitment to enter into appropriate<br />
arrangements <strong>for</strong> inpatient hospice beds, should the project be approved,<br />
with these being in local hospitals and skilled nursing facilities.<br />
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CON Action Number: 10061-10065<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065) utilized<br />
Medicare Hospice Standard Analytical File 2007 (issued by the Centers<br />
<strong>for</strong> Medicare and Medicaid Services) and meetings/interviews by VITAS<br />
staff with local leaders, to reach the following service area hospice unmet<br />
need conclusions: African-American patients, non-cancer patients 65<br />
years of age and older and rural Baker County.<br />
VITAS had the greatest number of support letters by local/regional and<br />
<strong>state</strong> African-American/Black oriented organizations (such as the<br />
Jacksonville Urban League). The applicant also discussed causes of<br />
death in the hospice service area in years 2006 through 2008 and <strong>state</strong>s<br />
that it will develop programs <strong>for</strong> patients with heart disease, Alzheimer‟s<br />
disease, HIV/AIDS and pulmonary conditions, offering specialized<br />
protocols <strong>for</strong> each diagnosis. VITAS also indicated that in many cases<br />
patients age 65 and older with a non-cancer diagnosis are already in<br />
nursing homes when hospice services commence and that VITAS has<br />
already worked with nursing homes in Florida to address this<br />
circumstance. VITAS has the most letters of commitment to enter into<br />
appropriate arrangements <strong>for</strong> inpatient hospice beds. All are with area<br />
skilled nursing facilities.<br />
A support letter from a <strong>state</strong>d board member of Jacksonville‟s Agape<br />
Community <strong>Health</strong> Center (the only support letter <strong>for</strong> any co-batched<br />
applicant from a federally qualified health center) also expressed<br />
awareness of hospice need and isolation in the Baker County area.<br />
There was also similar support through a letter from the Baker County<br />
Medical Services, Inc.<br />
The <strong>Agency</strong>‟s need methodology that resulted in published need <strong>for</strong> a new<br />
program in Hospice Service Area 4A showed the projected number of<br />
admissions minus the current number of admissions <strong>for</strong> the January<br />
2011 Hospice Planning Horizon as 925. Co-batched applicant Seasons<br />
Palliative <strong>Care</strong> of Florida, Inc. (CON #10063) proposed the greatest<br />
admission totals by year two of operations, followed by United Hospice of<br />
Florida, Inc. (CON #10064), Compassionate <strong>Care</strong> Hospice of Florida, Inc.<br />
(CON #10061), VITAS <strong>Health</strong>care Corporation of Florida (CON #10065)<br />
and Odyssey <strong>Health</strong>care of Collier County, Inc. (CON #10062):<br />
Total Projected Admissions By Applicant<br />
<strong>for</strong> Years One and Two<br />
CON # Applicant Year One Year Two Both Years<br />
10061 Compassionate <strong>Care</strong> 275 415 690<br />
10062 Odyssey 155 271 426<br />
10063 Seasons 402 615 1,017<br />
10064 United Hospice 222 528 750<br />
10065 VITAS 162 297 459<br />
Source: CON Application #’s 10061-10065.<br />
129
Quality of <strong>Care</strong>:<br />
CON Action Numbers: 10061-10065<br />
Each co-batched applicant offered evidence of its ability to provide<br />
quality care.<br />
Compassionate <strong>Care</strong> conditioned approval to become accredited by the<br />
Community <strong>Health</strong> Accreditation Program (CHAP) within 24 months of its<br />
initial licensure.<br />
Odyssey conditioned approval to become accredited by the Joint<br />
Commission and the National Institute <strong>for</strong> Jewish Hospice by the end of<br />
its second year of operation.<br />
Seasons proposes to condition approval to Joint Commission<br />
accreditation stating that “within the first two years, con<strong>for</strong>ming to the<br />
eligibility criteria <strong>for</strong> accreditation, begin the preparatory activities <strong>for</strong><br />
(Joint Commission) accreditation”.<br />
United Hospice conditioned approval on the provision that it will seek<br />
and obtain CHAP accreditation upon certification.<br />
VITAS does not propose to seek private organization accreditation.<br />
Regardless, Section 408.043 Florida Statutes (4) <strong>state</strong>s that<br />
“Accreditation by any private organization may not be a requirement <strong>for</strong><br />
the issuance or maintenance of a certificate of need under ss. 408.031-<br />
408.45.”<br />
Financial Feasibility/Availability of Funds:<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON #10061): Without<br />
results from operations, which were not available <strong>for</strong> <strong>Agency</strong> review, an<br />
analysis of the short and long-term strength of the applicant could not be<br />
made. However, funding <strong>for</strong> this project should be available as needed<br />
the project appears to be financially feasible.<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062): Funding <strong>for</strong> this project<br />
should be available as needed the project appears to be financially<br />
feasible.<br />
130
CON Action Number: 10061-10065<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063): Without<br />
results from operations, which were not available <strong>for</strong> <strong>Agency</strong> review, an<br />
analysis of the short and long-term strength of the applicant could not be<br />
made. However, funding <strong>for</strong> this project should be available as needed<br />
the project appears to be financially feasible.<br />
United Hospice of Florida, Inc. (CON #10064): Funding <strong>for</strong> this<br />
project should be available as needed. The project appears to be<br />
financially feasible.<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065): Funding <strong>for</strong><br />
this project should be available as needed the project appears to be<br />
financially feasible.<br />
Medicaid/Charity <strong>Care</strong>:<br />
CON<br />
Year One<br />
Medicaid<br />
Patient<br />
Days<br />
Hospice Service Area 4A<br />
Projected Medicaid and Charity <strong>Care</strong> Patient Days<br />
Year One<br />
Indigent/<br />
Self-Pay<br />
Patient Days<br />
Year One and Year Two<br />
131<br />
Year One<br />
Total<br />
Patient<br />
Days<br />
Year Two<br />
Medicaid<br />
Patient<br />
Days<br />
Year Two<br />
Indigent/<br />
Self-Pay<br />
Patient Days<br />
Year Two<br />
Total<br />
Patient<br />
Days<br />
10061 837 860 16,847 1,494 613 31,622<br />
10062 184 123 6,138 514 342 17,123<br />
10063 658 493 16,457 1,382 1,037 34,554<br />
10064 494 99 9,884 1,689 339 33,849<br />
10065 356 519 7,574 1,083 217 21,661<br />
Note: Obtained from applicant’s responses to Rule 59C-1.035(1) (i) Florida Administrative<br />
Code.<br />
Compassionate <strong>Care</strong> Hospice of Florida, Inc. (CON 10061): Schedule<br />
7A shows Medicaid is projected at five percent of year one and 4.7<br />
percent of year two patient days. The applicant projects $145,188 <strong>for</strong><br />
charity/self-pay (uncompensated) care in year one, and $102,810 <strong>for</strong><br />
charity care year two. Self-pay (uncompensated) care will account <strong>for</strong> 5.1<br />
percent of total patient days <strong>for</strong> year one and 1.9 percent of total patient<br />
days <strong>for</strong> year two (860 patient days and 613 patient days, respectively).<br />
Odyssey <strong>Health</strong><strong>Care</strong> of Collier County, Inc. d/b/a Odyssey<br />
<strong>Health</strong><strong>Care</strong> of Central Florida (CON #10062): Schedule 7A shows<br />
Medicaid is projected at three percent of year one and year two patient<br />
days. The applicant projects $27,823 <strong>for</strong> charity/self-pay care in year<br />
one, and $78,101 <strong>for</strong> charity care year two. According to the schedule<br />
notes, charity care is reflected in the self-pay column and is <strong>for</strong>ecasted at<br />
2.0 percent of patient days <strong>for</strong> both year one and year two (123 patient<br />
days and 342 patient days, respectively).
CON Action Numbers: 10061-10065<br />
Seasons Palliative <strong>Care</strong> of Florida, Inc. (CON #10063): Schedule 7A<br />
shows Medicaid is projected at four percent of year one and year two<br />
patient days. The applicant projects $0.00 <strong>for</strong> charity/self-pay care in<br />
year one, and $0.00 <strong>for</strong> charity care year two. However, the schedule<br />
estimates charity/other payers at $66,900 in year one and $143,600 <strong>for</strong><br />
charity/other payers year two. According to the schedule‟s notes, charity<br />
care, which is <strong>for</strong>ecasted to be provided to patients who can‟t pay and<br />
don‟t‟ qualify <strong>for</strong> Medicare or Medicaid or don‟t have a third party<br />
insurance plan which covers hospice services, has been recorded as<br />
“Other Payers”. Again, according to the schedule notes charity care is<br />
reflected in the self-pay column and is <strong>for</strong>ecasted at 0.5 percent of<br />
patient days <strong>for</strong> both year one and year two (82 patient days and 173<br />
patient days, respectively).<br />
United Hospice of Florida, Inc. (CON #10064): Schedule 7A shows<br />
Medicaid is projected at five percent of year one and year two patient<br />
days. The applicant projects $13,803 <strong>for</strong> charity care in year one, and<br />
$54,450 <strong>for</strong> charity care year two. For both year one and two, the<br />
applicant <strong>for</strong>ecasts 1.0 percent of patient days to charity care (99 patient<br />
days and 339 patient days, respectively).<br />
VITAS <strong>Health</strong>care Corporation of Florida (CON #10065): Schedule 7A<br />
shows Medicaid is projected at 4.7 percent of year one and five percent of<br />
year two patient days. The applicant projects $13,803 <strong>for</strong> charity care in<br />
year one, and $54,450 <strong>for</strong> charity care year two. For both year one and<br />
two, the applicant <strong>for</strong>ecasts 1.0 percent of patient days to charity care<br />
(99 patient days and 339 patient days, respectively).<br />
G. RECOMMENDATION<br />
Approve CON #10065 <strong>for</strong> the establishment of a new hospice program in<br />
Hospice Service Area 4A, consisting of Baker, Clay, Duval, Nassau and<br />
St. John‟s Counties. The proposed total project cost is $338,353 <strong>for</strong><br />
equipment, project development costs and start-up costs.<br />
CONDITIONS:<br />
The intent of VITAS <strong>Health</strong>care Corporation is to provide high quality,<br />
cost-effective and coordinated services <strong>for</strong> its patients/families and the<br />
community-at-large. The applicant will make a meaningful contribution<br />
to the defined underserved areas of African-American persons and those<br />
persons with non-cancer illnesses in need of hospice care. This will be<br />
accomplished through its proven experience and programming,<br />
successful operating model and assured via the conditions proposed by<br />
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CON Action Number: 10061-10065<br />
the applicant. VITAS <strong>Health</strong>care Corporation commits to the following<br />
core service, non-core service and operational/programmatic conditions<br />
identified below and commits to meet all of the requested <strong>report</strong>ing<br />
requirements and time frames as defined in Chapter 59C-1.013 and 59C-<br />
1.021, Florida Administrative Code.<br />
1. Percent of a particular population subgroup to be served.<br />
• The first population subgroup is defined as hospice patients in<br />
need of continuous care: VITAS <strong>Health</strong>care Corporation will<br />
provide at least three percent of its total patient days to<br />
continuous care by the end of year two. This will be measured<br />
via a signed declaratory <strong>state</strong>ment by VITAS <strong>Health</strong>care<br />
Corporation which may be supported via review of patient day<br />
<strong>report</strong>s by type and month produced by VITAS <strong>Health</strong>care<br />
Corporation.<br />
• The second population subgroup is defined as hospice patients<br />
with diagnosis other than cancer. The applicant will guarantee<br />
that at least 65 percent of patients admitted have non-cancer<br />
diagnoses. This will be measured via a signed declaratory<br />
<strong>state</strong>ment by VITAS <strong>Health</strong>care Corporation which may be<br />
supported via review of admission <strong>report</strong>s by patient diagnosis<br />
produced by VITAS <strong>Health</strong>care Corporation<br />
2. Special Programs: VHCF has conditioned the application on the<br />
provision it will meet or exceed the following quality and patient<br />
satisf<strong>action</strong> indicators:<br />
• Pain Control: On the first day of hospice care responsive<br />
patients will be asked to rate their pain on the 0-10 World<br />
<strong>Health</strong> Organization pain scale (severe pain to worst pain<br />
imaginable). A pain history will be created <strong>for</strong> each patient.<br />
These measures will be recorded in VITAS‟ proprietary<br />
in<strong>for</strong>mation management system, VITAS Exchange (or Wx") via<br />
a telephone call using the telephone keypad <strong>for</strong> data entry.<br />
These outcome measures will include greater than 70 percent of<br />
patients who <strong>report</strong> severe pain on a seven-10 scale will <strong>report</strong> a<br />
reduction to five or less within 48 hours. Florida Statutes<br />
400.60501 requires only a 50 percent reduction in 96 hours;<br />
this commitment set <strong>for</strong>th by VITAS far exceeds Florida<br />
statutory requirements and is a significant commitment to<br />
quality care.<br />
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CON Action Numbers: 10061-10065<br />
• Death Attendance: VITAS <strong>Health</strong>care Corporation will attend at<br />
least 90 percent of all deaths to ensure patients do not die<br />
alone. This will be measured via a signed declaratory <strong>state</strong>ment<br />
by VITAS which may be supported via review of patient medical<br />
records.<br />
• Patient Family Satisf<strong>action</strong>: VITAS <strong>Health</strong>care Corporation will<br />
achieve an overall patient satisf<strong>action</strong> score of 90 percent or<br />
above on patient's family evaluation of care while under the care<br />
of VITAS. This is determined by a mail-in survey sent by VITAS<br />
to the patient's family and measured by recording all scores.<br />
• Discipline Specific Satisf<strong>action</strong>: VITAS <strong>Health</strong>care Corporation<br />
will achieve an overall registered nurse satisf<strong>action</strong> score of 90<br />
percent or above on patient's family satisf<strong>action</strong> with the VITAS<br />
nurse while under the care of VITAS. This is determined by a<br />
mail-in survey sent by VITAS to the patient's family and<br />
measured by recording all scores.<br />
• Pet Therapy: Implementation of a pet therapy program to begin<br />
immediately. PetPals is a program where screened dogs visit<br />
shut-ins, nursing homes, assisted living facilities adult day care<br />
center and Alzheimer patients. This program offers a visit with<br />
a pet to those in the community who may respond to the love<br />
and com<strong>for</strong>t of a pet therapy dog. VITAS has an affiliation with<br />
the Central Florida Toy Dog Club which has sister organizations<br />
throughout the <strong>state</strong>. Volunteers and their pets are trained to<br />
assist patients and their families in any setting.<br />
3. Other Conditions: VITAS <strong>Health</strong>care Corporation has conditioned<br />
its application on the provision it will meet or exceed the following<br />
operational and programmatic indicators:<br />
• Establish satellite hospice offices in Baker and Nassau Counties<br />
during the first year of operation.<br />
• Implement a Tele<strong>Care</strong> Program consisting of 24/7 nurse<br />
availability to begin immediately.<br />
• Establish a Local Ethics Committee to begin upon certification,<br />
as discussed in Schedule B Section E2 of this application.<br />
• Implementation of <strong>Care</strong>PlanlT, a handheld bedside clinical<br />
in<strong>for</strong>mation system, by the end of the second year of operation.<br />
<strong>Care</strong>PlanlT is discussed in Schedule B Section E2.<br />
• Provide palliative radiation, chemotherapy and transfusions as<br />
appropriate <strong>for</strong> treating symptoms.<br />
• Provision of hospice services 24 hours a day, seven days a week<br />
as indicated by the patient's medical condition.<br />
• VITAS <strong>Health</strong>care Corporation will admit all eligible patients<br />
without regard to their ability to pay.<br />
134
CON Action Number: 10061-10065<br />
• Commit to having every patient being assessed by a physician<br />
upon admission to the hospice. Medical directors provide<br />
patient visits in their residence.<br />
• Medical directors must also be board-certified in hospice or<br />
palliative care medicine, or apply <strong>for</strong> board-certification within<br />
five years of employment.<br />
• RNs are encouraged to become certified in hospice and palliative<br />
care nursing. By the second year of operation, 50 percent of all<br />
supervisory nurses will attain such certification.<br />
• Chaplains are Masters of Divinity, demonstrated by completion<br />
of accredited CPE program.<br />
• Social workers are Master's level or licensed clinical social<br />
workers.<br />
• Designate a hospice representative to provide community<br />
outreach, promote hospice awareness and enhance access to<br />
African-American individuals in Subdistrict 4A.<br />
• A physician will serve as a member on every care team and<br />
provide patient visits as required.<br />
• Although bereavement services are generally provided to the<br />
family <strong>for</strong> one year after the death of the patient, services will be<br />
available beyond one year, if needed.<br />
• VITAS agrees that it will not solicit and will not accept<br />
donations from hospice patients, their families or the general<br />
community. VITAS will provide alternative hospice and charity<br />
in<strong>for</strong>mation to VITAS patients and their families and members<br />
of the community seeking to donate funds to hospice services.<br />
• Establish a clinical pastoral education program to begin<br />
immediately. The program description is found in TAB 10.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution in the amount of $300,000 to Florida State College<br />
at Jacksonville to fund an endowed teaching chair,<br />
scholarships, and the Northeast Florida Initiative <strong>for</strong> Nursing<br />
Work<strong>for</strong>ce Diversity. This will be initiated during its first year of<br />
licensure and will be measured via a signed declaratory<br />
<strong>state</strong>ment by VITAS and evidence of funds transferred. The<br />
correspondence between VITAS and Florida State College<br />
describing the uses of the donation is found in TAB 11.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution to United Way of Northeast Florida in the amount<br />
of up to $500,000 during the first three years of licensure. The<br />
United Way will serve as a charitable advisor to VITAS<br />
<strong>Health</strong>care Corporation identifying not-<strong>for</strong>-profit organizations<br />
in need of funding. The charitable contribution condition will<br />
be measured via a signed declaratory <strong>state</strong>ment by VITAS and<br />
evidence of funds transferred. The correspondence between<br />
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CON Action Numbers: 10061-10065<br />
VITAS and United Way of Northeast Florida describing the<br />
donation process is found behind TAB 11.<br />
• VITAS <strong>Health</strong>care Corporation will make a charitable<br />
contribution to the Jacksonville Urban League in the amount of<br />
$50,000 during the first year of licensure. The contribution will<br />
be used to expand several health and quality-of-life initiatives<br />
currently in place at Jacksonville Urban League <strong>for</strong> a client base<br />
which is predominantly the underserved African American<br />
population. The charitable contribution condition will be<br />
measured via a signed declaratory <strong>state</strong>ment by VITAS and<br />
evidence of funds transferred. The correspondence between<br />
VITAS and the Jacksonville Urban League describing the uses<br />
of the donation is found in TAB 11.<br />
Deny CON #‟s 10061, 10062, 10063 and 10064.<br />
136
AUTHORIZATION FOR AGENCY ACTION<br />
CON Action Number: 10061-10065<br />
Authorized representatives of the <strong>Agency</strong> <strong>for</strong> <strong>Health</strong> <strong>Care</strong> <strong>Administration</strong><br />
adopted the recommendation contained herein and released the State <strong>Agency</strong><br />
Action Report.<br />
DATE:<br />
James B. McLemore<br />
<strong>Health</strong> Services and Facilities Consultant Supervisor<br />
Certificate of Need<br />
Jeffrey N. Gregg<br />
Chief, Bureau of <strong>Health</strong> Facility Regulation<br />
137