state agency action report - Agency for Health Care Administration

STATE AGENCY ACTION REPORT 

ON APPLICATION FOR CERTIFICATE OF NEED 

A. PROJECT IDENTIFICATION 

1. Applicant/CON Action Number 

Compassionate Care Hospice of Florida, Inc./CON #10061 

18 Aquamarine Avenue 

Naples, Florida 34114 

Authorized Representative: Ms. Judith Grey 

(201) 919-4905 

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey 

HealthCare of Central Florida/CON #10062 

717 North Harwood, Suite 1500 

Dallas, Texas 75201 

Authorized Representative: Mr. Jason S. Howard 

(214) 922-9711 

Seasons Palliative Care of Florida, Inc./CON #10063 

6400 Shafer Court, Suite 700 

Rosemont, Illinois 60018 

Authorized Representative: Ms. Marcia Norman 

(847) 692-1127 

United Hospice of Florida, Inc./CON #10064 

1626 Jeurgens Court 

Norcross, Georgia 30093 

Authorized Representative: Mr. Neil L. Pruitt, Jr. 

(770) 925-4788

CON Action Numbers: 10061-10065 

VITAS Healthcare Corporation of Florida/CON #10065 

505 East Huntland Drive, Suite 270 

Austin, Texas 78752 

Authorized Representative: Ronald T. Luke, JD, PhD 

(512) 371-8166 

2. Service Area/Subdistrict 

Hospice Service Area 4A (Baker, Clay, Duval, Nassau, and 

St. Johns Counties) 

B. PUBLIC HEARING 

A public hearing was not held or requested regarding the proposals to 

establish a new hospice program in Hospice Service Area 4A. Letters of 

support are detailed below: 

Compassionate Care Hospice of Florida, Inc. (CON #10061) included 

two letters of support in its application and the Agency independently 

received one letter. All three letters were signed and dated during 

December 2009. Sandra L. Murman, former member of the Florida 

House of Representatives (1996-2004) stated she served as chair of the 

Health and Human Services Appropriations Committee and the Health 

Care Council. Representative Murman stated she has come to know 

Compassionate Care over the last year and that the organization has her 

highest respect. She also stated that she believes the applicant would 

bring a commitment to excellence and professionalism to the people of 

Duval and surrounding counties. James Wood, President and CEO, 

Memorial Hospital-Jacksonville and Thomas Pentz, Chief Executive 

Officer, Orange Park Medical Center (located in Clay County, Florida) 

submitted letters indicating that they would be willing to enter into 

appropriate agreements for the applicant to use their facility‟s hospital 

beds to provide inpatient level hospice care. 


HealthCare of Central Florida (CON #10062) submitted 46 

unduplicated letters of support. These letters were arranged in the 

following order: the Dream Foundation (one letter) acute care hospital, 

skilled nursing facility (SNF), assisted living facility (ALF) and related 

support (11 letters) and family letters of thanks (34 letters). 

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CON Action Number: 10061-10065 

Thomas Rollerson, Founder/President of the Dream Foundation, stated 

that his foundation is the first national wish-granting organization for 

adults 18 years of age or older with life-limiting illnesses, and that it was 

founded in Santa Barbara, California in 1994. According to Mr. 

Rollerson, the Dream Foundation is made possible in part by a grant 

from the Odyssey VistaCare Hospice Foundation and has had the 

pleasure of working with Odyssey‟s Florida programs by granting wishes 

to Florida patients. Mr. Rollerson stated that he has been impressed 

with Odyssey‟s dedication and that the company is a national provider of 

quality hospice services. 

The 11 support letters from a Hospice Service Area 4A acute care 

hospital, SNFs, ALFs and related facilities/providers were dated during 

November through December 2009. These were from James Wood, 

President and CEO, Memorial Hospital-Jacksonville; Kevin Harris, MSH, 

NHS, RHP, Executive Director, Administrator, W. Frank Wells Nursing 

Home (located in Baker County, Florida); Jacqueline Smith, RN, BSN, 

Director of Nursing, Jacksonville Nursing and Rehab Center; Neil 

Ramski, NHA, Administrator, Cedar Hills Healthcare Center; Paul Callis, 

Director of Social Services, Moultrie Creek Nursing and Rehabilitation 

Center (St. Johns County, Florida); John Schaum, Executive Director, 

Sunrise Assisted Living of Jacksonville and Barbara Tidwell, RD, LD, 

MHA, FACHE, Owner/Administrator, Some Place Like Home, Inc. A 

recurring theme is that increased competition and choice will enhance 

existing hospice services. The hospital and SNF support letters make no 

mention of entering into appropriate agreements for the applicant to use 

hospital or SNF beds to provide inpatient-level hospice care. Ms. Tidwell 

of Some Place Like Home, Inc. (an ALF) specifically expresses concern 

with the existing hospice landscape in Hospice Service Area 4A regarding 

a need for more communication with family during the dying process. 

The 34 support letters of thanks from family members served by the 

applicant were mostly hand written notes and cards of appreciation for 

the care provided a loved one. Five of these were from Daytona Beach, 

six had a Miami-Dade County, Florida address but most did not 

distinguish a location. 

Seasons Palliative Care of Florida, Inc. (CON #10063) submitted 105 

unduplicated letters of support and the Agency received one support 

letter independently. These were categorized by the applicant as 17 

professional and 89 family and friend support letters. 

The applicant‟s 17 professional support letters were from Florida and 

non-Florida hospitals, a Florida university professor, a Hospice Service 

Area 4A local bank, non-Florida medical doctors, non-Florida nursing 

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homes, and Seasons Hospice staff. All of these letters were signed and 

most were dated December 2009. A sampling of these follows: Hoyt 

Ross, Chief Executive Officer, Kindred Hospital - North Florida (Clay 

County, Florida); staff from Henry Ford Hospital (located in Detroit, 

Michigan); Martin Gorbien, MD, Rush University Medical Center (located 

in Chicago, Illinois); Christopher Holroyde, MD, Phoenixville Hospital 

(located in Phoenixville, Pennsylvania); Caprice Knapp, PhD, Assistant 

Professor, University of Florida College of Medicine and Liz Porter, 

Business Development Specialist, Heritage Bank of North Florida (located 

in Clay County, Florida). Mr. Ross, of Kindred Hospital - North Florida, 

stated he would welcome the applicant into his facility and is willing to 

contract for general inpatient levels of care. Mr. Ross‟ letter is not dated. 

Caprice Knapp, PhD, of the University of Florida‟s College of Medicine 

stated she is impressed by the applicant‟s devotion to providing pediatric 

palliative care and the Kangaroo Kids program in Chicago. Dr. Gorbien 

of Rush University Medical Center commented on the applicant‟s “open 

access” program. Dr. Gorbien stated this program allows individuals in 

hospice to continue to receive certain treatments or procedures that 

might be considered too aggressive (i.e., highly costly), by other hospices. 

Matthew Shuster, MD, Co-Medical Director, Seasons Hospice and 

Palliative Care of Massachusetts described “open access” as a policy in 

which no patient is rejected simply because they choose to continue 

some element of life-sustaining therapy. The Agency recognizes that as 

part of Season‟s admissions policy, the patient/legal representative must 

make an informed decision to forego curative treatment for the terminal 

illness in preference for palliative treatment/services. A recurring theme 

is that increased competition and choice will enhance existing hospice 

services. 

The 89 unduplicated support letters of thanks from family members 

served by the applicant were mostly hand written notes and cards of 

appreciation for the care provided a loved one. None were from Florida 

residents, as the applicant does not operate in Florida. Many of the 

letters were not dated and did not distinguish a location. Most expressed 

exceptional thanks and gratitude for hospice services provided to family, 

friends or loved ones. The Agency notes the many comments in these 

support letters and cards about the applicant providing services beyond 

those commonly or frequently offered by hospice providers (such as 

ventilator care). Many of these cited the applicant‟s promptness, genuine 

caring and attentiveness to patient and family needs. 

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United Hospice of Florida, Inc. (CON #10064) submitted 63 

unduplicated letters of support and the Agency received two support 

letters for this applicant independently. The applicant categorized these 

letters as follows: community and United Hospice staff (20 letters); UHS- 

Pruitt subsidiaries (five letters) and United Hospice patients and families 

(39 letters). 

The 21 unduplicated support letters from the community and United 

Hospice staff were all signed or at least had distinguishing applicable 

provider letterhead. Most were signed between November 12 and 

December 14, 2009. A sample of these support letters include: James 

Wood, President and CEO, Memorial Hospital-Jacksonville; Hoyt Ross, 

CEO and Administrator, Kindred Hospital-North Florida (located in Clay 

County, Florida); Kevin Harris, MSH, NHA, CASP, Administrator, W. 

Frank Wells Nursing Home; Tamara Patton, Coordinator, Emergency 

Services and Homeless Coalition of Jacksonville, Inc.; Brian Snow, 

Director of Family Services, I.M. Sulzbacher Center for the Homeless; 

Ju‟Coby Pittman-Peele, CEO/President, Carla White Mission, Inc.; Mark 

Landschoot, Executive Director, Family Promise of Jacksonville; Julie 

Wood, BSRN, Nurse Care Coordinator, The Medical Home for Homeless 

Children Project; Van Snead, Home Safe Program Manager, Presbyterian 

Social Ministries, Inc.; Mary Canestorp, Administrator, Buckingham 

Smith Assisted Living Facility (located in St. Johns County, Florida); Paul 

Callis, MS, Social Services Director, Moultrie Creek Nursing and 

Rehabilitation Center and Andrew McCraw, MD, McCraw Family 

Medicine (located in Simpsonville, South Carolina). Many of these 

support letters had an emphasis on care for the homeless (both adults 

and children). Ms. Canestrop stated that she has met with United 

Hospice representatives and believes they share “our quality and 

compassion to provide our residents with the highest level of care”. She 

also stated that her facility is affiliated with the St. Johns Welfare 

Federation. Bill Saunders, RN, BSN, MBA, Administrator, Confident 

Care of Florida Corp (located in Jacksonville, Florida) and Carol Waters, 

life coach, licensed massage therapist, hypnotist, and Clay County 

resident, expressed dissatisfaction with the current hospice environment 

in Hospice Service Area 4A, with Mr. Saunders commenting on decreased 

care of hospice patients in some instances, particularly with regard to 

nursing care. Ms. Waters stated that existing hospices in the area are 

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less receptive to massage, aroma and music therapy than the applicant. 

Gayle Eckerd, Chief Executive Officer, River Point Behavioral Health and 

Wekiva Springs Center for Women (both located in Duval County, 

Florida); John Griggers, Administrator, Life Care Center of Orange Park, 

(Clay County, Florida) and Stephen Jordan, Administrator, Quality 

Health of Fernandina Beach (Nassau County, Florida) indicated their 

willingness to contract or enter into appropriate arrangements with the 

applicant for general inpatient levels of care. 

The five letters from UHS-Pruitt subsidiaries were signed with a 

December 9, 2009 signature date. All signatories indicate a location of 

Norcross, Georgia. Richard Gerhardt, Vice President of Health Services 

issued two of the five letters. Mr. Gerhardt indicated that his company 

would provide appropriate medical equipment and supplies. Other 

subsidiary letters indicated interest in providing pharmacy, nutritional, 

dietary counseling, physical, occupational, speech and respiratory 

therapy and related services. 

The 39 unduplicated support letters of thanks from family members 

served by the applicant were mostly hand written notes and cards of 

appreciation for the care provided to a loved one/family member. Many 

of these thank United Hospice and some Peachtree Christian Hospice (a 

Georgia Hospice managed by UHS). Many of the letters and cards were 

not dated. Of those dated, the year was 2008 or 2009. 

VITAS Healthcare Corporation of Florida (CON #10065) submitted 53 

unduplicated letters of support and the Agency independently received 

two letters of support. Nearly all were signed and all have applicable 

affiliate letterhead; most are dated December 2009. The letters are 

described below in the following order: those received by the Agency 

independently, three found in CON Application #10065, Tab 11- 

Charitable Contribution Condition Letters and 50 letters in Tab 15-Letter 

of Support. The applicant‟s Tab 15 included a list of these „noncharitable 

contribution‟ condition letters. Four support letters lack a 

signature: John Drew, Tax Collector, Nassau County, Florida; Sharon 

James, President, Daytona Beach Black Nurses Association; Leonard 

Love, Archbishop, Truth for Living Ministries (Duval County, Florida) and 

Nancy Austin, RN, CHPN, Chapter President, Hospice and Palliative 

Nurses Association (Miami-Dade County, Florida). Thirty-seven of the 55 

support letters have a Hospice Service Area 4A address. The support 

letters are identified by the following groups: charitable contribution 

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letters, elected officials, willingness to contract letters, Hospice Service 

Area 4A support, and non-Hospice Service Area 4A support. A relatively 

common theme is the applicant‟s seeking to provide hospice services to 

the African American population, the HIV/AIDS population and patients 

with other non-cancer diagnosis that are in need of hospice service. 

Michele Querry, Director of Major Gifts, Florida State College Foundation 

provided a $298,690 proposal stated to outline unique partnership 

opportunities for VITAS to assist in the Foundation‟s „critical funding 

needs‟, $285,000 of which will be submitted for State matching funds 

and $13,690 matched by the Foundation for Florida‟s Community 

Colleges for the Blue Cross Blue Shield of Florida Nursing and Allied 

Health Scholarship. The State matching funds consist of $190,000 for 

the Northeast Florida Initiative for Nursing Workforce Diversity, $55,000 

for a VITAS Innovative Hospice Care Endowed Teaching Chair and 

$40,000 for a VITAS Innovative Hospice Care Endowed Scholarship. 

Barbara Drake, Chair, Board of Directors and Connie Hodges, President, 

United Way of Northeast Florida, stated that the United Way would be 

willing to steward a VITAS gift of up to $500,000 that would span over a 

two to three year period beginning in the summer of 2010. According to 

this letter, the funds would be used to expand the Elder Care Advocacy 

Program provided to Shands Jacksonville Medical Center. Richard 

Danford, President, Jacksonville Urban League (JUL) indicated that a 

proposed $50,000 VITAS grant would be used to support anti-obesity 

programs promoted by the JUL, educational end-of-life JUL quarterly 

seminars and workshops and expansion of JUL community health and 

end-of-life care awareness initiatives. 

Eight elected officials support the applicant‟s proposal. These officials 

include: the Honorable Audrey Gibson, District 15, Florida House of 

Representatives; the Honorable Stacey Johnson, County Commissioner, 

Nassau County Board of County Commissioners; the Honorable John 

Drew, Tax Collector, Nassau County; the Honorable Tommy Hazouri, 

Representative, Duval County School Board and the Honorable Richard 

Clark (Council President), William Bishop, AIA, Michael Corrigan, Jr. and 

Warren Jones, Councilmen, Office of the City Council, City of 

Jacksonville. These letters indicated that VITAS is a leader in end-of-life 

care and would make an excellent additional choice of hospice providers 

in the area. 

Representatives of six Hospice Service Area 4A skilled nursing facilities 

expressed commitment or interest in entering into appropriate 

agreements to provide inpatient hospice beds, should this applicant be 

approved. These providers are: Chris Adams, Executive Director; Harts 

Harbor Health Care Center; Elizabeth Sholar, NHA, Fleet Landing; 

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Raymond Prudencio, NHA, CNA, Administrator and Preceptor, The 

Terrace at Fleming Island (Clay County, Florida); Glenford Wright, 

MSHRM, BSBA, Administrator, West Jacksonville Health and 

Rehabilitation Center; Jerry Tomack, MHSA, NHA, Executive Director, 

San Jose Health and Rehabilitation Center and Eric Weisz, Executive 

Director, Governor‟s Creek Health and Rehabilitation Center (Clay 

County, Florida). 

Letters from Hospice Service Area 4A were received from Neal Henning, 

PhD, Dean of Workforce Development, Florida State College of 

Jacksonville, Dr. Steven Wallace, President, Dr. Barbara Darby, North 

Campus/Nassau Center President and Gwendolyn Yates, Vice Chair, 

Duval County, District Board of Trustees, Florida State College at 

Jacksonville. Kevin Harris, MSH, Administrator, W. Frank Wells Nursing 

Home stated confidence that residents of his county will significantly 

benefit from this project, if approved. Archbishop Leonard Love, Truth 

for Living Ministries, stated interest in the applicant‟s cultural sensitivity 

to the African American community. Deborah Thompson, Owner, 

Deborah Thompson Consultants identified herself as a Board Member of 

the Jacksonville Urban League and Agape Community Health Center, a 

federally qualified health center [FQHC], and stated that VITAS is a 

proven leader with a record of accomplishments and that she is confident 

that VITAS will implement out-reach programs for the African-American 

community. 

Many of the applicant‟s letters of support from outside Hospice Service 

Area 4A attest to VITAS‟ success in other parts of Florida and the nation. 

These include Jerry Santeiro, Executive Director, Guardian Program of 

Dade County, Inc., Public Guardian for the 11th Judicial Circuit (Miami- 

Dade County, Florida), Linda Quick, President, South Florida Hospital & 

Healthcare Association cited the success VITAS has experienced in the 

South Florida area particularly with African American and terminally ill 

non-cancer patients. Max Rothman, JD, LLM, President and CEO, 

Alliance for Aging, Inc. (Miami-Dade and Monroe Counties, Florida) also 

cited the applicant‟s excellent service to the African American terminally 

ill and indicated that like results might be realized in Hospice Service 

Area 4A with approval of this applicant. Maria Lazo, Miami-Dade County 

Hispanic Affairs Advisory Board Director, indicated that VITAS has 

community outreach programs which recognize that hospice outreach is 

necessary for persons of Hispanic descent and African American descent, 

and that those with non terminal illnesses are better served. She stated 

that she is confident VITAS will address these needs in District 4A. 

Sharon Jones, President, Daytona Beach Black Nurses Association, 

stated that VITAS has provided scholarships for student nurses at 

Daytona State College and at Bethune Cookman University for the past 

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four years, has been especially sensitive to African American end-of-life 

issues and is uniquely qualified to provide culturally appropriate 

information, services and care to African Americans and traditionally 

underserved populations. Maria Pams, MHS, Project Director, Senior 

Community Services Program, American Association of Retired Persons 

(Miami-Dade County, Florida) recognized the applicant‟s success in 

reaching out to the African American population in her area. Martha 

Sanchez, Chief Executive Officer, Area Health Education Center (Miami- 

Dade County) makes similar comments. Nancy Auster, RN, CHPN, 

Chapter President, Hospice and Palliative Nurses Association (Miami- 

Dade County, Florida) stated that the applicant will provide a 

tremendous service to the underserved of the area, particularly the 

African American community. Deborah Alexander, President, the 

Amyotrophic Lateral Sclerosis (ALS) Association of Florida Chapter 

(Hillsborough County, Florida), indicated that VITAS has consistently 

demonstrated commitment to ALS patients. Marco Carrasco, NHA, 

MHSA, Administrator, West Gables Health Care Center and Region 1 

Vice President, Florida Health Care Association, indicated that VITAS‟s 

programs bring value to his community and would bring similar value to 

the proposed area. Barbara Grasch, LMFT, Director of Program Services, 

Alzheimer‟s Association Southeast Florida Chapter (Palm Beach County, 

Florida), and Patricia Lange, Executive Director, Florida Assisted Living 

Association (located in Tallahassee, Florida) also submitted letters of 

support. 

Support letters from national African American organizations were also 

included in the application. Iva Carruthers, PhD, General Secretary, 

Samuel DeWitt Proctor Conference, Inc. (located in Chicago, Illinois), 

indicated that VITAS has had success with hospice care from an African 

American faith perspective. Bishop Arthur House, Jr., Full Gospel 

Baptist Church Fellowship International, Office of Home Missions 

(located in Hampton, Virginia) also indicated that VITAS has had 

successful efforts to reach out to the African American community 

concerning end-of-life concerns. Millicent Gorham, Executive Director, 

National Black Nurses Association, Inc. stated that for the past five years 

VITAS has provided continuing education programs at her organization‟s 

national conferences including one in Broward County, Florida in 2006. 

Ms. Gorham also indicated that recently, principals from VITAS engaged 

the Daytona Beach Black Nurses Association to discuss issues around 

end-of-life care. 

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Summary of Contractual Letters of Support 


CON Application #10061 (Compassionate Care) included two acute 

care hospital letters of willingness to provide inpatient beds for hospice 

services – one from Memorial Hospital-Jacksonville (Duval County) and 

one from Orange Park Medical Center (Clay County). 

CON Application #10062 (Odyssey) does not include an acute care 

hospital or SNF commitment letter to enter into inpatient bed 

arrangements. 

CON Application #10063 (Seasons) included a letter of willingness from 

Kindred Hospital-North Florida to provide inpatient beds for hospice 

services. 

CON Application #10064 (United) included four letters of willingness to 

provide inpatient beds for hospice services. These were from River Point 

Behavioral Health which also operates Wekiva Springs Center for Women 

(Duval County inpatient psychiatric hospitals) and two SNFs – Quality 

Health of Fernandina Beach (Nassau County) and Life Care Center of 

Orange Park (Clay County). 

CON Application #10064 (VITAS) included six letters of willingness 

from SNF providers to provide inpatient beds for hospice services. Two of 

these are located in Clay County, The Terrace at Fleming Island and 

Governor‟s Creek Health and Rehabilitation Center and four are Duval 

County nursing homes: Fleet Landing, Harts Harbor Health Care Center, 

San Jose Health and Rehabilitation Center and West Jacksonville Health 

and Rehabilitation Center. 

C. PROJECT SUMMARY 

Compassionate Care Hospice of Florida, Inc. (CON #10061), a forprofit 

provider, proposes the establishment of a new hospice program in 

Hospice Service Area 4A, consisting of Baker, Clay, Duval, Nassau and 

St. Johns Counties. Compassionate Care was founded in 1993 and has 

developed 23 start-up hospice programs in 15 states: Delaware, Georgia, 

Illinois, Kansas, Massachusetts, Michigan, Minnesota, Missouri, 

Nebraska, New Jersey, New York, Pennsylvania, South Dakota, Texas 

and Wisconsin. Compassionate Care also has CON approval via CON 

#10036 to establish a program in Hospice Service Area 6B and states 

this program is projected to be operational in February 2010. According 

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to the applicant, Compassionate Care is an expert in start-up operations, 

in programs that are opened in markets with existing providers and that 

none of its programs were “purchased” from other providers. 

Compassionate Care states that it will aggressively address the unmet 

hospice need in Hospice Service Area 4A, and will seek to identify and 

serve any underserved groups (racial, religious, financial, diagnostic 

category). 

Compassionate Care states that it will establish three office locations 

upon commencement of services including one in Duval County (zip code 

32218), one in Clay County in the Orange Park area (zip code 32073) and 

one in St. Johns County (zip code 32092). The applicant states these 

three locations, in total, will serve the entirety of the hospice service area. 

The applicant is proposing total project costs of $227,616 for equipment, 

project development and start-up costs. 

In its Schedule C, the applicant includes the following general statement 

of conditions and proposes eight specific conditions: 

Compassionate Care Hospice’s General Statement on Willingness to 

Accept Conditions in Service Area 4A 

It has become a routine practice for many hospice organizations to 

provide the various required components of hospice services through 

lengthy listing of numerous specific conditions for award of the CON. As 

required by law, Compassionate Care Hospice is willing to accept any 

such conditions on its CON based on any representations made 

throughout this CON application. 

Compassionate Care will provide all of the required components of 

hospice care, and meet all Medicare conditions of participation, and 

Florida hospice licensure requirements, including the provision of all 

levels of services (routine home care, continuous care, general inpatient, 

respite) to all type of patients (cancer, non-cancer, Alzheimer's, COPD, 

elderly, young adult, pediatric) without regard to race, ethnicity, gender, 

age, religious affiliation, diagnosis, financial status, insurance status, or 

any other discriminating factor. 

Compassionate Care commits to offering excellent quality specialized and 

individualized programs delivered by highly qualified interdisciplinary 

teams of professionals, and will implement continuous quality 

improvement, performance improvement, quality assurance and 

monitoring programs. Compassionate Care will offer all types of services 

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including physical care and pain management, bereavement counseling 

and support services (for as long as the bereaved needs such services, 

without limitation on duration), psycho-social services, spiritual care and 

counseling, memorial programs and services, palliative radiation or 

chemotherapy, and massage, music, pet, aroma, and other alternative 

therapy programs. Compassionate Care will implement a volunteer 

program and offer a wide array of services through its volunteers. 

Compassionate Care is firmly committed to the continuing and ongoing 

training, orientation, and education of its staff, and will implement 

specific programs such as tuition reimbursement, ongoing in-service and 

training programs, library resources and payment for certification of 

staff. Compassionate Care will ensure that its staff has the resources, 

equipment (such as laptop computers, Personal Digital Assistants, or 

other IT equipment) to perform effectively in the delivery of care to their 

patients and families. 

Compassionate Care will conduct extensive community education and 

outreach programs in all communities, including all racial, ethnic, or 

religious minority communities, Veterans groups and organizations, and 

will initiate specialized programs and services to meet the individual 

needs of such communities in terms of language needs or specialized 

cultural or religious needs. Examples include such programs as 

Compassionate Care's Jewish Hospice Certification, use of a culturally 

diverse staff, use of bilingual staff, and production of education materials 

and service forms in Spanish, Vietnamese, Russian or other languages as 

needed in the community; and sensitivity and training for the special 

needs of veterans. 

Compassionate Care will contribute to community organizations 

including universities, community colleges or other organizations 

involved in the training of health care professionals, or in the delivery of 

social services to the community. 

Compassionate Care will provide services beyond those mandated and 

reimbursed by Medicare and Medicaid, including specific financial 

assistance to meet the special individualized needs of patients through 

its charitable foundation, including special "last wishes" of a patient or 

family, need for specialized equipment not reimbursable, travel for a 

special family member to visit with a dying patient, or simply need for 

assistance with mortgage payment, rent, utilities, groceries, or other 

necessities. 

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Compassionate Care believes that all of the above types of programs, 

services, policies, and protocols should be provided by any hospice 

provider, and therefore would accept as a condition to its CON approval 

any or all of these general conditions. 

However, in order to assist the Agency in distinguishing Compassionate 

Care from other applicants, the applicant offers the following specific 

conditions, that are aimed at specific measurable actions that will 

increase access and quality of care for hospice patients. 

Specific Conditions 

1. Office Locations: In order to increase awareness and visibility of 

hospice services in the 3,221 square miles that represent 

Subdistrict 4A 1 (Baker, Clay, Duval, Nassau, and St. John's 

Counties) and to provide for accessible meeting places for 

interdisciplinary care teams, bereavement support groups, family 

counseling meetings and sessions, community education meetings, 

and other types of local activities, Compassionate Care commits to 

opening three office locations upon commencement of services 

including one in Duval County (zip code 32218), targeted to 

meeting needs in Duval and Nassau Counties; one in Clay County 

in the Orange Park area (zip code 32073), targeted to meeting 

needs of Clay County, Baker County, and southwest Duval 

County; and one in St. John's County in zip code 32092 targeted 

to meeting the needs of St. Johns County and specifically west St. 

Johns. Compliance with this condition will be measured by 

providing to the Agency the location addresses for each office upon 

commencement of services. 

2. Program Accreditation: As a demonstration of commitment to 

quality, Compassionate Care will become accredited by the 

Community Health Accreditation Program within 24 months of its 

initial licensure. Compliance will be demonstrated by forwarding a 

copy of the accreditation to the Agency. 

1 CON Application #10061, page #4. 

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3. Medical Directors: Medical directors will assess every patient upon 

admission to hospice, and will provide patient visits in the home or 

place of residence. Medical directors will either be board-certified 

in hospice and palliative care medicine, or will apply for boardcertification 

within five years of employment as medical director. 

Compliance will be demonstrated through an annual report to the 

Agency. 

4. Community/Education Outreach Coordinator: In order to 

continuously assess the needs of the community, to expand the 

information base in regard to the benefits of hospice care, and to 

reach populations in need that may not be easily accessible 

through the health care referral system, Compassionate Care will 

provide a full-time dedicated staff member, located in the 

Jacksonville office and serving all five counties, with the exclusive 

responsibility of serving as a community outreach coordinator to 

the non-health care community. This individual will work closely 

with the community leaders and organizations in the subdistrict 

focused on seeking to identify unmet hospice need in underserved 

populations, providing hospice information and educational 

sessions to inner city and other area churches, civic organizations, 

employers, and advocacy groups such as AAA, area offices on 

aging, cancer support groups. Compliance will be demonstrated in 

an annual report to the Agency which identifies the key activities of 

this position on no less than a monthly basis. 

5. Pain Reduction: Compassionate Care will effectively reduce severe 

pain in its hospice patients within 48 hours of admission to 

hospice. Compliance may be demonstrated based upon an annual 

report of Compassionate Care‟s initial pain scores for patients, and 

recorded pain scores after 48 hours. Compassionate Care will 

achieve a reduction for at least 75 percent of patients with severe 

pain (score of seven to 10) to a pain score of five or less within 48 

hours of admission. This exceeds the requirement in Section 

400.60501, Florida Statutes. 

6. Other Staff Qualifications: To ensure high quality, Compassionate 

Care will adopt the following standards and qualifications for staff: 

registered nurses will be encouraged to become certified in hospice 

and palliative care nursing, and by the third year of operation, 50 

percent of all supervisory nurses shall attain such certification, 

with 100 percent of all supervisory nurses attaining such 

certification by the fifth year of operation; chaplains shall be 

masters of divinity, with demonstrated completion of an accredited 

clinical pastoral education program; social workers shall be 

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masters level and licensed clinical social workers. Compliance 

with these qualifications shall be demonstrated in an annual 

report to the Agency. 

7. Continuous Care: Compassionate Care commits that it will 

provide at least 1.5 percent of total patient days as continuous 

care days. They plan to have continuous care staff at the bedside 

within two hours of receipt of a request for such services and will 

maintain the service until no longer needed. Compliance will be 

measured and demonstrated by maintaining records of requests 

for continuous care and providing an annual report to the Agency 

on response times and total patient days. See Appendix R for 

additional information on continuous care at Compassionate Care. 

8. Patient Visits: Compassionate Care will commit that every patient 

shall be contacted on a daily basis to determine their needs for the 

day, and all patients shall receive in-person visits from 

Compassionate Care staff at least five times per week for at least 

two hours per day. Compliance will be monitored by submitting an 

annual report to the Agency. 


HealthCare of Central Florida (CON #10062), a for-profit provider, 

proposes the establishment of a new hospice program in Hospice Service 

Area 4A, consisting of Baker, Clay, Duval, Nassau and St. Johns 

Counties. The applicant states its sole shareholder and parent is 

Odyssey HealthCare Operating B, LP, founded in 1995. The parent is 

stated to have approximately 92 Medicare-certified hospice programs in 

29 states. The applicant also indicates that rather than attempting to be 

“all things to all people” it chooses to focus solely on hospice care and on 

its core competencies, particularly clinical competencies and its 

CareBeyond program, in which disease-specific hospice care is applied to 

applicable patients. The applicant also states affiliation with two existing 

Florida hospices owned and operated by the parent – Odyssey 

Healthcare/Daytona (Hospice Service Area 4B) and Odyssey 

Healthcare/Miami (Hospice Service Area 11) 2 . Odyssey HealthCare‟s two 

Florida hospices were initially licensed during 2005 and 2006, 

respectively. The applicant indicates that the parent is finalizing 

licensure and expects to open its third Florida hospice program, Odyssey 

HealthCare of Marion County, Inc. (Hospice Service Area 3B) in early 

2010 3 . The applicant states that “special and not normal circumstances” 

exist in Hospice Service Area 4A and that the specific terminally ill 

2 Odyssey HealthCare of Marion County, Inc. is licensee for Service Areas 4B & 11 effective 11-1-09. 

3 Odyssey HealthCare of Marion County, Inc. added Marion County to its license effective 1-1-2010. 

15


population not being adequately served is as follows: cancer patients age 

65 years and older; non-cancer patients under the age of 65 years and 

non-cancer patients age 65 years and older. 

Odyssey conditions (condition #21 below) CON approval to the immediate 

development of its main office in Duval County and two satellite offices, 

one in Clay County by the end of year one of operation and a second 

satellite office in Nassau County by the end of year two of operation. 

The applicant is proposing total project costs of $666,972 for equipment, 

project development and start-up costs. 

In its Schedule C, the applicant proposes 25 itemized conditions, as 

follows: 

1. The applicant will provide supportive hospice services, such as but 

not limited to: palliative radiation therapy and palliative 

chemotherapy related to the patient‟s terminal diagnosis. This will 

be measured via a signed declaratory statement by the applicant, 

which may be supported via a review of patient medical records. 

2. The applicant will provide continuous care. This will be measured 

via a signed declaratory statement by the applicant, which may be 

supported via a review of patient medical records. 

3. The applicant will implement the “Care Beyond” program. This will 

be measured via a signed declaratory statement by the applicant. 

4. The applicant will provide hospice services 24 hours a day, seven 

days a week including weekend care as indicated by the patient‟s 

medical condition. This will be measured via a signed declaratory 

statement by the applicant, which may be supported via a review 

of patient medical records. 

5. The applicant will admit all eligible patients without regard to their 

ability to pay. This will be measured by the applicant‟s Medicare 

certification which requires this standard. 

16


6. The applicant commits to having every patient being assessed by a 

physician upon admission to the hospice. This will be measured 

via a signed declaratory statement by the applicant, which may be 

supported via a review of patient medical records. 

7. The applicant will immediately implement its performance 

improvement plan including the following assessments: pain 

management, family satisfaction, employee satisfaction, and 

referral source satisfaction. This will be measured via a signed 

declaratory statement by the applicant, which may be supported 

via a review of patient medical records. 

8. The applicant will make available a range of non-covered 

supplementary therapies such as but not limited to: pet, music, 

massage, aroma and other holistic treatments. This will be 

measured via a signed declaratory statement by the applicant, 

which may be supported via a review of patient medical records. 

9. The applicant will implement Odyssey‟s triage and on-call 

programs upon licensure. These programs provide for 

uninterrupted 24-hour care seven days a week. Further 

explanation of the program is offered in the application narrative. 

This will be measured via a signed declaratory statement by the 

applicant. 

10. The applicant will establish a local ethics committee within the 

first year of operation. This will be measured via submissions of 

the names and other relevant information of the Ethics Committee 

members and the related schedule of meetings to the Agency. 

11. The applicant will establish a local medical advisory committee 

within the first year of operation. This will be measured via 

submissions of the names and other relevant information of the 

medical advisory committee members and the related schedule of 

meetings to the Agency. 

12. The applicant will provide educational programs, including but not 

limited to, in-service training (components of Odyssey University) 

resources to the community, including nursing homes, assisted 

living facilities, Council on Aging. In-service training would be 

offered to registered nurses, social workers, administrators and 

other staff that would benefit from an increased knowledge of 

hospice care and services. The applicant will host at least one 

seminar annually during the first two years of operation for clergy 

17


and community faith leaders (The Clergy End of Life Education 

Program), to enhance spiritual support for hospice patients in the 

district. This will be measured via a signed declaratory statement 

by the applicant. 

13. The applicant will provide patients, family members and referral 

sources with information of services provided by the Dream 

Foundation. The Dream Foundation is the first national group of 

its kind that exists for terminally ill applicants over the age of 18. 

Through its Day Dreams (a program for terminally ill adults over 

the age of 65), Emergency Dreams and Quality of Life Dreams, the 

Dream Foundation provides patients and families with a sense of 

completion and fulfillment. Odyssey has partnered with the Dream 

Foundation to improve care for our patients and to advance our 

mutual interests in the field of hospice. This will be measured via 

a signed declaratory statement by the applicant. 

14. The applicant, through Odyssey HealthCare, Inc. or the Odyssey 

VistaCare Hospice Foundation, will make a $25,000 contribution 

to an appropriate not-for-profit entity in the community to fund 

education for end-of-life issues. Upon approval, Odyssey will meet 

with the Area Council on Aging or similar organization to identify 

and determine the most appropriate entity within the community 

related to education for end-of-life issues. This will be measured 

via a signed declaratory statement by the applicant and evidence of 

funds provided to the not-for-profit entity. 

15. The applicant will commit to 0.5 FTE the first year of operation to 

evaluate the need, if any, for an expanded children‟s hospice 

program in the community including, but not limited to, the need 

for a children‟s program that offers an expanded hospice benefit for 

patients up to age 21. The program would focus on longer term 

services for patients who may not otherwise qualify for hospice 

such as those with developmental conditions, cancers, chronic 

illnesses or brain injury that shorten lives and place special 

demands on families. If during the first year of operation it is 

determined that existing children‟s hospice services in the 

community are available to meet local needs, the applicant will 

donate $25,000 to support existing local children‟s hospice 

programs. If after the first year there is found to be a need for 

additional children‟s hospice services, a child and family support 

program interdisciplinary team will be established to support the 

needs of this target population. This will be measured via a signed 

declaratory statement by the applicant. 

18


16. The applicant will commit to 0.5 FTE the first year of operation 

regarding community bereavement programs in the community. 

The bereavement program will be broadly based to extend beyond 

the families of patients admitted to Odyssey HealthCare. These 

programs will be an extension of the programs currently offered in 

the hospice service area. The applicant will provide bilingual staff 

to provide bereavement services to the Hispanic population, 

including Hispanic children. At a minimum, one bereavement 

group consisting of approximately eight sessions will be offered by 

the end of the first year of operation. As the bereavement client 

census increases after one year, full-time staff will be employed. 


applicant. 

17. The applicant will commit to the provision of programs for the 

Hispanic and other minority populations which will include 

support from or involvement of bilingual staff, translated literature, 

training on cultural differences and competencies and flexible 

programming to meet their unique needs. Hospice staffing will 

reflect the racial and ethnic mix of the local community served. 


applicant. 

18. The applicant will develop a community resource library during the 

first year of the proposed hospice‟s operation. The library will 

include various lay and professional education pieces related to 

chronic illness, death, dying and bereavement. This will be 

measured via a signed declaratory statement by the applicant. 

19. The applicant commits that the Odyssey VistaCare Hospice 

Foundation will facilitate the provision of a children‟s bereavement 

camp in Florida by the end of the first year of operation, similar to 

what Odyssey currently provides via Odyssey‟s SkyCamp, Camp 

Healing Tree and Camp Odyssey. This will be measured via a 

signed declaratory statement by the applicant. 

20. The applicant will have a minimum of at least three community 

education representatives, expanding community awareness of 

hospice services and educating local medical staff, community 

leaders and potential hospice patients as to the benefits of and 

availability of hospice care. Compliance with this condition will be 

measured via submission of an annual report confirming that at 

least three CER staff members are employed at the proposed new 

19


service and active in the local community. Additionally, if 

approved, Odyssey will provide education, training and assistance 

in development of respite care policies, procedures and protocols to 

nursing homes. 

21. Satellite offices: Hospice Service Area 4A includes five counties: 

Baker; Clay; Duval; Nassau and St. Johns. Odyssey commits to 

the immediate development of its main office in Duval County and 

two satellite offices; one satellite in Clay County by the end of year 

one of operation and a second satellite office in Nassau County by 

the end of year two of the operation. 

22. The applicant commits to become accredited by the Joint 

Commission and the National Institute for Jewish Hospice by the 

end of its second year of operation. 

23. The applicant commits to medical directors assessing every patient 

on admission and providing visits in home or place of residence. 

Medical director to be board-certified in hospice and palliative care 

medicine or will apply for board-certification within five years of 

employment. 

24. The applicant commits that every patient will be contacted on a 

daily basis. 

25. The applicant commits to sponsoring two to four education 

seminars per year for physicians, long-term care facilities and 

ALFs. The focus of these seminars is to educate the local health 

care community on the provision of hospice services within ALFs 

and other long-term care facilities: a coordinated plan of care for 

the patient, increased support for patient, family and facility staff, 

and the provision of equipment, medication and supplies. 

Seasons Palliative Care of Florida, Inc. (CON #10063), a for-profit 

provider, proposes the establishment of a new hospice program in 


St. Johns Counties. The applicant states that it operates hospice 

programs in 10 states: California, Delaware, Illinois, Indiana, Maryland, 

Massachusetts, Michigan, Pennsylvania, Texas and Wisconsin. The 

applicant currently has no CON approved or licensed hospice programs 

in Florida. According to the applicant, it promotes a patient focused 

“Circle of Care” program strategy in which the patient and family form 

the hub from which needs emanate. In this strategy, the applicant states 

every patient will have dignity throughout the end-of-life process, pain 

will be controlled and wishes will be met. In addition, the applicant 

20


states commitment to what is stated as the fundamental principal upon 

which the program was founded - to die at home. The applicant 

proposes to specifically serve what it finds as the following two 

underserved groups – cancer patients age 65 and older and non-cancer 

patients age 65 and older. 

The applicant indicates that it will establish a main office in Clay County, 

near or in Orange Park. 

The applicant is proposing total project costs of $658,585 for building, 

equipment, project development and start-up costs. 

In its Schedule C, the applicant includes the following 20 itemized 

conditions: 

Initiated within the First Two Years 

1. Location in Clay County 

• Will locate the main office in Clay County 

• Measurement: Provide a physical location and street address in 

Clay County 

2. $50,000 outreach, promotion and expansion of hospice services in 

Clay County 

• Within six months of final approval of the CON, Seasons will 

meet with the Chairman of the Board of County Commissioners 

(and others as directed) on how best to establish a transparent 

process to allow for the donation and expenditure of $50,000 to 

promote outreach and education of hospice services. 

• Measurement: Status report to Agency for Health Care 

Administration regarding the process and procedures, with final 

notification of donated funds. 

3. $15,000 pilot project on outcome measures for two areas: 

infections and falls 

• Within six months of licensure, meet with representatives of the 

Agency and Department of Elder Affairs to review the process 

and procedures for the pilot program to collect data and 

development measures within the areas of infections and falls to 

design best practices. 

21


• Upon approval of the process and procedures by the pilot 

project committee, Seasons will begin data collection and 

analysis, submitting the information as scheduled to the 

Department of Elder Affairs. 

• By end of the second year, Seasons will complete the pilot 

program designed to report outcome measures to the Agency 

and to the Department of Elderly fairs relating to the provision 

of hospice services. 

• Measurement: Periodic status reports as scheduled by the 

oversight committee, with a final report (in the third year), and 

recommended best practices for preventing infections and falls 

among hospice patients. 

4. Seek and maintain accreditation by The Joint Commission 

• Within the first two years, conforming to the eligibility criteria 

for accreditation, begin the preparatory activities for 

accreditation. 

• Measurement: Once accreditation is achieved, provide a copy of 

accreditation to the Agency and to the Department of Elder 

Affairs, and provide copies of renewals thereafter. 

Broad Community Benefits 

5. Seasons Hospice & Palliative Care Newsletter and the monthly 

news letter PharmSmart. These newsletters are designed to 

transmit the latest research and information on hospice and 

palliative care, with a focus on professionals, physicians, physician 

assistants, nurse practitioners, and nurses (available to patients 

and families as well). The PharmSmart newsletter is written by a 

pharmacist and used for education for the community including 

physicians and pharmacists. 

• By the end of the first year have published at least one edition 

of each newsletter and made it available within the service area. 

• Measurement: Provide a copy of each issue of the newsletters 

to the Agency and to the Department of Elder Affairs. 

6. CEU provider for nursing and social workers 

• By the end of the second year, have established approval to 

provide continuing education units for licensed nurses and 

licensed social workers. 

22


• Measurement: Provide the Agency with copy of the education 

provider number from the Florida Board of Nursing as well the 

Florida Board of Clinical Social Work, Marriage and Family 

Therapy, and Mental Health Counseling and schedule of 

courses, days and times. 

7. Voluntary submission of county level data to the Department of 

Elder Affairs and to The Agency on admissions by age, disease 

categories, place of admission, time to assessment, time to 

enrollment, length of stay, and visits 

• By the end of the second year, provide county level data to the 


• Measurement: Submission of county level data defined above. 

8. 2.5 percent of admissions for uncompensated care 

• Measurement: Confirmed by the annual report to the 


Special Programs 

9. Palliative radiation 

• Provide palliative radiation as prescribed in the plan of care. 

• Measurement: Report annually to the Agency the numbers of 

patients and numbers of treatment receiving palliative 

radiation. 

10. Palliative chemotherapy 

• Provide palliative chemotherapy as prescribed in the plan of 

care. 


patients and numbers of treatment receiving palliative 

chemotherapy. 

11. Ventilator-dependent in home care to permit the person to die on 

the ventilator, which differs from compassionate weaning 

• Provide ventilator-in-home care to hospice patients as 

prescribed in the plan of care. 


patients who received in-home care on a ventilator. 

23


12. Kangaroo Kids-pediatric program for terminally ill children 

• Provide the program designed for terminally ill children. 


pediatric patients treated. 

13. Kangaroo Camp at Florida Resort for terminally ill children and 

families 

• By the end of the second year, have scheduled a Kangaroo 

Camp. 

• Measurement: Provide notification to the Agency of the 

scheduled camp and information on location. 

14. A Touch for All Seasons-Alzheimer's Disease and other dementia 

• Implement the program. 

• Measurement: Report annually to the Agency on the numbers 

of patients enrolled in the A Touch for All Seasons. 

15. Partnership in Caring-nursing home program, education of facility 

staff 

• Implement the program 

• Measurement: Report annually to the Agency on the numbers 

of facilities participating in the program and the names of those 

facilities and the numbers of staff educated at those facilities. 

16. Music Therapy Program-provided by a music therapist employed 

by the hospice and part of the care team 

• Provide music therapy as a standard core service as prescribed 

in the plan of care. 

• Measurement: Report annually the number of patients who 

received music therapy and the number of music therapy visits 

delivered. 

17. Dieticians employed by the hospice and part of the care team 

• Employ one more dieticians (based on staffing ratios). 

• Measurement: Report the number of dieticians employed 

annually to the Agency. 

24

Operational Initiatives for Enhanced Quality 


18. Implement and maintain electronic medical records 

• Implement the electronic medical record. 

• Measurement: Status report to Agency on the use of the 

electronic medical records. 

19. Call Center - 24 hours a day, seven days a week, staffed with 

Seasons employees, Seasons operates its own call center, fully 

integrated, for the hospice in 4A, and fully integrated with the 

electronic medical record for real time responses-tracking, and 

assignment of assessments. 

• Integrate hospice program in Service Area 4A for ongoing 

operations. 

• Measurement: Report the number of calls by day of week and 

time of day by month and response time to calls with status of 

admissions. 

20. Local Advisory Board - guide identification of needs, review 

locations for access points, branch offices, and inpatient capability 

• By the end of the first year, establish an advisory board. 

• Measurement: Provide the Agency with names of board 

members and roles and responsibilities of the board members, 

terms of service, and schedule of meetings. For ongoing 

operations, provide copies of meeting minutes and reports on 

activities. 

United Hospice of Florida, Inc. (CON #10064), a for-profit provider, 

proposes the establishment of a new hospice program in Hospice Service 

Area 4A, consisting of Baker, Clay, Duval, Nassau and St. Johns 

Counties. 

The parent, United Health Services, Inc. (UHS), is a member of the UHS- 

Pruitt family of companies which has its corporate office in Norcross, 

Georgia. UHS-Pruitt Corporation was founded in 1969 as the Toccoa 

Nursing Center in North Georgia. UHS is a holding company which owns 

and/or operates, through its subsidiaries, 71 long-term care facilities, 25 

hospice programs (in Georgia, South Carolina and North Carolina), 13 

25


home health care agencies, five pharmacies, a health care management 

company, a nutritional services company, a clinical services company, a 

medical supply company and 14 SOURCE offices 4 . Presently, neither the 

applicant nor the parent has licensed or CON approved hospice programs 

in Florida. 

The applicant proposes a main office in Duval County, in the City of 

Jacksonville, and two satellite offices in rural areas of Hospice Service 

Area 4A – a Baker County office to be opened immediately upon licensure 

and a Nassau County office to be opened by the end of the second year of 

operation. The applicant also proposes to become a member of and 

partner with the St. Johns Rural Health Network 5 . According to what the 

applicant calls its in-depth market field survey and analysis efforts, it 

has identified the populations it believes are in greatest need of hospice 

services in the area and states greater emphasis will be directed to the 

following: rural areas that are currently underserved by existing hospice 

providers, outreach to the African American community, outreach to the 

homeless and mentally ill populations and outreach to the non-cancer 

terminally-ill populations. 

The applicant is proposing total project costs of $251,232.72 for 

equipment, project development and start-up costs. 

In its Schedule C, the applicant includes a brief conditions statement 

and itemizes the following 10 specific conditions: 

United Hospice of Florida, Inc. - Conditions of the Application, 

Subdistrict 4A, Florida 

United Hospice of Florida states that “reflective of its commitment to 

serve any and all terminally-ill residents of Subdistrict 4A, UHF is willing 

to accept any such conditions on its certificate of need based on any 

representations made throughout this document. The applicant will 

provide all required core components of hospice care set forth by 

Medicare conditions of participation as well as Florida hospice licensure 

requirements including the provision of all four levels of service (routine, 

continuous care, general inpatient and respite) to all types of patients 

without regard to race, ethnicity, gender, age, religious affiliation, 

4 The State of Georgia & UHS-Pruitt websites indicate UHS-Pruitt subsidiary UniHealth Solutions 

oversees UHS participation in SOURCE, which the State of Georgia‟s Medicaid long-term care diversion 

program. 

5 According to the Florida Department of Health, Office of Rural Health, Baker and Nassau Counties 

are classified by the State of Florida as rural counties, pursuant to Florida Statutes 381.0406 and 

these two counties are among the counties within the St. Johns River Rural Health Network. 

http://www.doh.state.fl.us/Workforce/RuralHealth/ruralhlthnetworks.htm 

26


diagnosis, financial status, insurance status or any other discriminating 

factor. Specific conditions to be met by United Hospice of Florida, if 

awarded a CON to provide hospice services to Subdistrict 4A residents, 

are as follows: 

1. United Hospice Home and Community Based Services Provider: 

Upon CON approval, United Hospice's ultimate parent, UHS, will 

develop, in conjunction with United Hospice, UHS' family of 

services and companies in Subdistrict 4A and will enhance the 

hospice services available to area residents by making such 

services available not only to United Hospice's patients, but also to 

any other existing hospice provider who wishes to contract for 

such services. The UHS family of services and companies include 

United Home Care, United Medical, United Pharmacy Services and 

United Clinical Services. This will be measured by a signed 

declaratory statement submitted by United Hospice to the Agency. 

2. African American Outreach: Reflective of its commitment to 

enhancing access to the end-of-life care of African American 

residents in Subdistrict 4A, the applicant has conditioned approval 

of its application on the provision it will implement and maintain 

an African American Outreach Program. 

• A staff member will be responsible for the outreach initiatives. 

This individual's objective will be to coordinate staff activities, 

plan events and serve as a key contact within community 

leaders. 

• United Hospice will form a planning and outreach team 

consisting of staff, volunteers and community members. This 

team will provide support for the staff person assigned primary 

responsibility for outreach effort. 

• United Hospice will host listening sessions with African 

American leaders, African American clergy and other members 

of the African American community to develop an 

understanding of attitudes and beliefs regarding end-of-life 

care. Some of these organizations will include but are not 

limited to: 

• Local NAACP branches 

• Jacksonville Urban League 

• Black Chamber of Commerce 

• Jacksonville City Mayor's office 

• State Representative Mia Jones 

• State Senator Tony Hill Sr. 

• State Representative Audrey Gibson 

27


• Other City and County Leaders 

• Churches and other religious affiliated groups 

• Based on listening sessions, the applicant will develop a 

message, presentation and marketing materials that address 

needs and issues expressed by focus group respondents to 

ultimately deliver the message that addresses needs and 

concerns of the community. 

• United Hospice will continually assess existing tools and 

obtain or develop new resources as needed to provide 

culturally meaningful and appropriate educational 

opportunities for the African American community. 

• The applicant will provide ongoing comprehensive training 

for staff and volunteers who are actively involved in the 

outreach program. These individuals will plan quarterly 

town hall meetings with members of the community to 

engage, educate and energize individuals to begin end-of-life 

conversations in their organizations, congregations and so 

forth. 

• United Hospice will develop and maintain a calendar of 

events that address, support and celebrate African American 

issues, heritage and health care concerns. Staff members 

will attend various calendar events with the goal of making 

United Hospice of Florida the name and face known 

throughout the community. 

• The applicant will develop a census tracking tool to routinely 

track referrals generated by the outreach program to 

measure its ongoing success. 

• The applicant will report its admissions annually by race, to 

measure success and increase in percentage of African 

American admissions. 

This condition will be measured by a signed affidavit submitted to the 


3. Homeless Outreach: If awarded a certificate of need for the 

proposed project, United Hospice will partner with the ESHC to 

provide hospice services to Subdistrict 4A homeless individuals in 

either a residential or homeless shelter setting coordinated by 

ESHC. Specifically, United Hospice will accept the following 

conditions on its CON: 

• Continue active membership in the ESHC through attendance 

at monthly meetings and collaborating with coalition members 

in providing services to the homeless population. 

28


• Provide hospice services to homeless population in shelters and 

assist with facility placement as appropriate. Shelters may 

include but are not limited to City Rescue Mission, Hubbard 

House, the Salvation Army, the Sulzbacher Center and Trinity 

Rescue Mission. 

• United Hospice will provide health screenings by a registered 

nurse once a month at one of the local not-for-profit social 

service organizations to be determined in collaboration with the 

ESHC. 

These homeless related activities will be measured by United Hospice's 

submission of a homeless activity report which will accompany its 

Annual Report to Department of Elder Affairs. 

4. Rural Areas Outreach: United Hospice has conditioned this 

application on the provision it will open a main office in 

Jacksonville plus two satellite offices in rural areas of Subdistrict 

4A as follows: 

• A Baker County office will open immediately upon licensure to 

serve the terminally-ill needs of Baker County residents. 

• A Nassau County office will open by the end of United Hospice's 

second year of operation. 

• Both the Baker and Nassau County offices will be centrally 

located to the population and will have a dedicated 

interdisciplinary team. 

• United Hospice will become a member of and will partner with 

the St. Johns Rural Health Network to improve the health of the 

communities in which United Hospice serves. 



5. Patients in Need of Continuous Care: United Hospice has 

conditioned this application on the provision it will provide, at a 

minimum, 2.5 percent of its patient days by the end of year two to 

continuous care which exceeds the state average, to the extent in 

which there is patient demand as determined by the 

interdisciplinary team. This condition will be measured via a 

signed declaratory statement by United Hospice which may be 

supported via review of patient day reports by type and month 

produced by the applicant. United Hospice will monitor and 

annually report to the Agency, overall Subdistrict 4A continuous 

care percentage of patient days to determine success of its 

continuous care initiative. 

29


6. CHAP Accreditation: United Hospice has conditioned approval of 

this application on the provision it will seek and obtain CHAP 

accreditation upon certification. This will be measured by 

submitting United Hospice's accreditation certificate to the Agency 

upon receipt. 

7. Membership Organizations: Upon licensure, UHF will become a 

member of the following community organizations: 

• Florida Hospice and Palliative Care; 

• Jacksonville Regional Chamber of Commerce; 

• St. Johns County Chamber of Commerce; 

• Greater Nassau County Chamber of Commerce; 

• Clay County Chamber of Commerce; and 

• Baker County Chamber of Commerce. 

This will be measured by a signed affidavit submitted to the Agency. 

8. United Hospice Foundation: United Hospice Foundation will make 

available to Florida residents, its annual scholarship program 

targeted at those who are studying nursing, pharmacy or therapy 

with an interest in end-of-life care. The scholarship is available 

each year to four students in the amount of $2,000 for the school 

year. This will be measured by a signed affidavit submitted to the 


9. Staffing Ratios and Qualification: United Hospice will meet or 

exceed all NHPCO Guidelines for qualifications and staffing ratios 

for patient care staff. This will be measured by a signed 

declaratory affidavit submitted to the Agency. 

10. Pain Reduction: United Hospice will implement rapid pain 

management protocols to ensure that 75 percent of patients who 

report severe pain on a 0-10 scale will report a reduction to five or 

less by the end of the second day of care on the hospice program. 

This condition substantially exceeds the requirements of section 

400.60501, Florida Statutes. For patients that do not meet this 

pain reduction goal, such patient's plan of care will be evaluated 

within 48 hours by the medical director and a Pharm D. 

consultant to ensure that appropriate pain reduction measures are 

immediately implemented. 

30


VITAS Healthcare Corporation of Florida (CON #10065), a for-profit 

entity, proposes the establishment of a new hospice program in Hospice 

Service Area 4A, consisting of Baker, Clay, Duval, Nassau and St. Johns 

Counties. 

VITAS is a Florida-based entity, headquartered in Miami, Florida, that 

has been operating in Florida for over 30 years and has licensed hospice 

programs in the following eight hospice service areas: 4B (Flagler and 

Volusia Counties), 7A (Brevard County), 7B (Orange and Osceola 

Counties), 7C (Seminole County), 8B (Collier County), 9C (Palm Beach 

County), 10 (Broward County), and 11 (Miami-Dade and Monroe 

Counties). The applicant indicates that if the project is approved, its new 

hospice program in Hospice Service Area 4A will be operated under one 

of its three existing licenses. The applicant also indicates it operates 43 

hospice programs nationwide, spread among 16 states and the District of 

Columbia. VITAS Healthcare Corporation‟s focus is on terminally ill 

patients and their families and is not a full continuum of health care 

services. As such, the applicant believes since its hospice services are 

not an adjunct to nursing home or home health services, its attention is 

not diluted by other product or business lines. 

The applicant proposes a main office in Duval County, in the City of 

Jacksonville, and two satellite offices in Hospice Service Area 4A, in 

Baker and Nassau Counties. The two satellites are to be created during 

the first year of operation. The applicant believes residents of Clay and 

St. Johns Counties will be adequately supported from the main office in 

Jacksonville. According to the applicant, based on its review of the 

Medicare Hospice Standard Analytical File 2007 (issued by the Centers 

for Medicare and Medicaid Services) and meetings/interviews by VITAS 

staff with local leaders, the following conclusions were reached in 

pinpointing underserved populations in Hospice Service Area 4A: noncancer 

patients 65 years of age and older, African-American patients and 

the lowest hospice admission rate (per 100 residents) in the hospice 

service area being in Baker County. 

The applicant is proposing total costs of $338,353 for equipment, project 

development costs and start-up costs. 

In its Schedule C, the applicant includes a brief conditions statement 

and itemizes three primary conditions as follows: 

The intent of VITAS Healthcare Corporation is to provide high quality, 

cost-effective and coordinated services for its patients/families and the 

community-at-large. The applicant will make a meaningful contribution 

to the defined underserved areas of African-American persons and those 

31


persons with non-cancer illnesses in need of hospice care. This will be 

accomplished through its proven experience and programming, 

successful operating model and assured via the conditions proposed by 

the applicant. VITAS Healthcare Corporation commits to the following 

core service, non-core service and operational/programmatic conditions 

identified below and commits to meet all of the requested reporting 

requirements and time frames as defined in Chapter 59C-1.013 and 59C- 

1.021, Florida Administrative Code. 

1. Percent of a particular population subgroup to be served. 

• The first population subgroup is defined as hospice patients in 

need of continuous care: VITAS Healthcare Corporation will 

provide at least three percent of its total patient days to 

continuous care by the end of year two. This will be measured 

via a signed declaratory statement by VITAS Healthcare 

Corporation which may be supported via review of patient day 

reports by type and month produced by VITAS Healthcare 

Corporation. 

• The second population subgroup is defined as hospice patients 

with diagnosis other than cancer. The applicant will guarantee 

that at least 65 percent of patients admitted have non-cancer 

diagnoses. This will be measured via a signed declaratory 

statement by VITAS Healthcare Corporation which may be 

supported via review of admission reports by patient diagnosis 

produced by VITAS Healthcare Corporation 

2. Special Programs: VHCF has conditioned the application on the 

provision it will meet or exceed the following quality and patient 

satisfaction indicators: 

• Pain Control: On the first day of hospice care responsive 

patients will be asked to rate their pain on the 0-10 World 

Health Organization pain scale (severe pain to worst pain 

imaginable). A pain history will be created for each patient. 

These measures will be recorded in VITAS‟ proprietary 

information management system, VITAS Exchange (or Wx") via 

a telephone call using the telephone keypad for data entry. 

These outcome measures will include greater than 70 percent of 

patients who report severe pain on a seven-10 scale will report a 

reduction to five or less within 48 hours. Florida Statutes 

400.60501 requires only a 50 percent reduction in 96 hours; 

this commitment set forth by VITAS far exceeds Florida 

statutory requirements and is a significant commitment to 

quality care. 

32


• Death Attendance: VITAS Healthcare Corporation will attend at 

least 90 percent of all deaths to ensure patients do not die 

alone. This will be measured via a signed declaratory statement 

by VITAS which may be supported via review of patient medical 

records. 

• Patient Family Satisfaction: VITAS Healthcare Corporation will 

achieve an overall patient satisfaction score of 90 percent or 

above on patient's family evaluation of care while under the care 

of VITAS. This is determined by a mail-in survey sent by VITAS 

to the patient's family and measured by recording all scores. 

• Discipline Specific Satisfaction: VITAS Healthcare Corporation 

will achieve an overall registered nurse satisfaction score of 90 

percent or above on patient's family satisfaction with the VITAS 

nurse while under the care of VITAS. This is determined by a 

mail-in survey sent by VITAS to the patient's family and 

measured by recording all scores. 

• Pet Therapy: Implementation of a pet therapy program to begin 

immediately. PetPals is a program where screened dogs visit 

shut-ins, nursing homes, assisted living facilities adult day care 

center and Alzheimer patients. This program offers a visit with 

a pet to those in the community who may respond to the love 

and comfort of a pet therapy dog. VITAS has an affiliation with 

the Central Florida Toy Dog Club which has sister organizations 

throughout the state. Volunteers and their pets are trained to 

assist patients and their families in any setting. 

3. Other Conditions: VITAS Healthcare Corporation has conditioned 

its application on the provision it will meet or exceed the following 

operational and programmatic indicators: 

• Establish satellite hospice offices in Baker and Nassau Counties 

during the first year of operation. 

• Implement a TeleCare Program consisting of 24/7 nurse 

availability to begin immediately. 

• Establish a Local Ethics Committee to begin upon certification, 

as discussed in Schedule B Section E2 of this application. 

• Implementation of CarePlanlT, a handheld bedside clinical 

information system, by the end of the second year of operation. 

CarePlanlT is discussed in Schedule B Section E2. 

• Provide palliative radiation, chemotherapy and transfusions as 

appropriate for treating symptoms. 

• Provision of hospice services 24 hours a day, seven days a week 

as indicated by the patient's medical condition. 

• VITAS Healthcare Corporation will admit all eligible patients 

without regard to their ability to pay. 

33


• Commit to having every patient being assessed by a physician 

upon admission to the hospice. Medical directors provide 

patient visits in their residence. 

• Medical directors must also be board-certified in hospice or 

palliative care medicine, or apply for board-certification within 

five years of employment. 

• RNs are encouraged to become certified in hospice and palliative 

care nursing. By the second year of operation, 50 percent of all 

supervisory nurses will attain such certification. 

• Chaplains are Masters of Divinity, demonstrated by completion 

of accredited CPE program. 

• Social workers are Master's level or licensed clinical social 

workers. 

• Designate a hospice representative to provide community 

outreach, promote hospice awareness and enhance access to 

African-American individuals in Subdistrict 4A. 

• A physician will serve as a member on every care team and 

provide patient visits as required. 

• Although bereavement services are generally provided to the 

family for one year after the death of the patient, services will be 

available beyond one year, if needed. 

• VITAS agrees that it will not solicit and will not accept 

donations from hospice patients, their families or the general 

community. VITAS will provide alternative hospice and charity 

information to VITAS patients and their families and members 

of the community seeking to donate funds to hospice services. 

• Establish a clinical pastoral education program to begin 

immediately. The program description is found in TAB 10. 

• VITAS Healthcare Corporation will make a charitable 

contribution in the amount of $300,000 to Florida State College 

at Jacksonville to fund an endowed teaching chair, 

scholarships, and the Northeast Florida Initiative for Nursing 

Workforce Diversity. This will be initiated during its first year of 

licensure and will be measured via a signed declaratory 

statement by VITAS and evidence of funds transferred. The 

correspondence between VITAS and Florida State College 

describing the uses of the donation is found in TAB 11. 


contribution to United Way of Northeast Florida in the amount 

of up to $500,000 during the first three years of licensure. The 

United Way will serve as a charitable advisor to VITAS 

Healthcare Corporation identifying not-for-profit organizations 

34


in need of funding. The charitable contribution condition will 

be measured via a signed declaratory statement by VITAS and 

evidence of funds transferred. The correspondence between 

VITAS and United Way of Northeast Florida describing the 

donation process is found behind TAB 11. 


contribution to the Jacksonville Urban League in the amount of 

$50,000 during the first year of licensure. The contribution will 

be used to expand several health and quality-of-life initiatives 

currently in place at Jacksonville Urban League for a client base 

which is predominantly the underserved African American 

population. The charitable contribution condition will be 

measured via a signed declaratory statement by VITAS and 


VITAS and the Jacksonville Urban League describing the uses 

of the donation is found in TAB 11. 

ALL: None of the applicants proposed to condition to voluntary reporting 

of the Agency‟s „Family Evaluation of Hospice Care (FEHC) Satisfaction 

Survey‟ found at the FloridaHealthFinder.gov website. Hospice programs 

are required by federal and state law to provide services to everyone 

requesting them and therefore the Agency would not place conditions on 

a program to provide legally required services. Rule 59C-1.013(4) Florida 

Administrative Code contains condition compliance reporting criteria 

that the Agency uses for an approved CON that has conditions. 

D. REVIEW PROCEDURE 

The evaluation process is structured by the certificate of need review 

criteria found in Section 408.035, Florida Statutes, rules of the State of 

Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code. 

These criteria form the basis for the goals of the review process. The 

goals represent desirable outcomes to be attained by successful 

applicants who demonstrate an overall compliance with the criteria. 

Analysis of an applicant's capability to undertake the proposed project 

successfully is conducted by evaluating the responses provided in the 

application, and independent information gathered by the reviewer. 

Applications are analyzed to identify various strengths and weaknesses 

in each proposal. If more than one application is submitted for the same 

type of project in the same district (subdistrict or service planning area), 

applications are comparatively reviewed to determine which applicant 

best meets the review criteria. 

35


Section 59C-1.010(3)(b), Florida Administrative Code, prohibits any 

amendments once an application has been deemed complete. The 

burden of proof to entitlement of a certificate rests with the applicant. As 

such, the applicant is responsible for the representations in the 

application. This is attested to as part of the application in the 

certification of the applicant. 

As part of the fact-finding, the consultant, Steve Love, analyzed the 

application in its entirety with consultation from financial analyst, 

Derron Hillman, who evaluated the financial data. 

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA 

The following indicates the level of conformity of the proposed projects 

with the criteria found in Florida Statutes, Sections 408.035 and 

408.037; applicable rules of the State of Florida, Chapter 59C-1 and 

59C-2, Florida Administrative Code. 

1. Fixed Need Pool 

a. Does the project proposed respond to need as published by a fixed 

need pool? Chapter 59C-1.008, Florida Administrative Code and 

Chapter 59C-1.0355, Florida Administrative Code. 

In Volume 35, Number 39 of the Florida Administrative Weekly, dated 

October 2, 2009, the Agency for Health Care Administration published a 

need for one hospice program in AHCA Hospice Service Area 4A (Baker, 

Clay, Duval, Nassau and St. Johns Counties) for the January 2011 

Hospice Planning Horizon. Hospice Service Area 4A is currently served 

by the following three licensed hospice providers: Community Hospice of 

Northeast Florida, Inc.; Haven Hospice and Heartland Home Health Care 

and Hospice (the latter being licensed effective 9/6/07). 

Each co-batched applicant is applying in response to published need for 

a hospice program in Hospice Service Area 4A (Baker, Clay, Duval, 

Nassau and St. Johns Counties). However, how each co-batched 

applicant addresses existing unmet need to support their project is 

briefly described below. 

Compassionate Care Hospice of Florida, Inc. (CON #10061) relies 

upon the Agency‟s stated fixed need pool for one additional hospice 

program in the service area but also uses additional justification. 

36


Compassionate Care provided a detailed description of the Agency‟s 

hospice need calculation on pages 36-41. Beginning at the middle of 

page 41 and continuing to the middle of page 45, the applicant compares 

the service area with the state projections by diagnostic category and age 

(i.e. cancer age under 65 and 65 and over, and „all other‟ age under 65 

and 65 and over). They conclude that the service area is underserved in 

all categories especially in the age 65 and over „other‟ category. Since 

there is a need for one program, this is not an unexpected result. 

The applicant‟s Table 1 (CON #10061, page 11) documented the state‟s 

annual hospice “unmet need” (actual admissions minus projected 

admissions) by planning horizon and service area from January 2006 – 

January 2011. This table demonstrates that Service Area 4A is 

consistently showing need in that the gap between current hospice 

admissions and projected horizon year admissions has consistently been 

above 350 (ranging from 676 to 1,118). Every planning horizon 

calculation would result in need for a new hospice, except that the 

service area has had approved hospices in operation for less than two 

years during several of these periods. Service Area 4A and Service Area 

11 (Miami-Dade and Monroe Counties) are the only service areas where 

this has occurred. 

Compassionate Care indicates that it undertook an extensive community 

assessment to determine unmet hospice need. This included phone 

calls, personal meetings and a survey questionnaire sent to 242 

providers. The application‟s Appendix P–Community Assessment Survey 

Instrument includes the survey cover letter, needs questionnaire and a 

mailing list of local hospitals, nursing homes, assisted living facilities, 

end-stage renal disease centers, adult day care, and adult family home 

care facilities. According to the applicant, the survey responses were 

anonymous and included a response rate of approximately four percent. 

This is a low response rate. Compassionate Care indicated that the a 

specific unmet need was not identified; there was need for support 

services for staff in nursing homes after they experienced a loss of a longterm 

resident and some respondents identified patients‟ need for IV pain 

medications but it was not clear from the comments whether the services 

were not available or whether the need was a consistent need of the 

facility‟s hospice patients. The respondents welcomed Compassionate 

Care‟s potential entry into the local hospice market. 

Compassionate Care indicates that numerous brochures about the 

applicant‟s hospice program were sent to providers in the area. The 

applicant has 15 general marketing brochures and five pediatrics 

brochures. 

37


According to the applicant, written letters of support were “thwarted” 

because few individuals were willing or interested in getting into the 

“politics” of CON. Potential supporters also indicated they did not want 

to upset existing providers or were overwhelmed by the number of 

applicants and decided not to support anyone. The Agency notes the 

applicant submitted the fewest letters of support of any co-batched 

applicant. 

Compassionate Care contends that the hospice service area is 

geographically challenged to meet hospice need. The applicant states 

that its discussions with existing health care providers and surveys 

demonstrate a full range of services and support activities in the market 

and that the existing Community Hospice of Northeast Florida has the 

greatest number of office locations. However, there are no offices in Clay 

or Baker County, there is one in Nassau and multiple offices in Duval 

and St. Johns. Compassionate Care states that a significant number of 

potential cases are not receiving care most likely due to geographic 

access issues and/or provider resource constraints. While this is not 

well documented, there is a projected need for an additional program and 

the applicant provides a map of the service area‟s existing and its 

proposed locations on page 48 of the application. United Hospice (CON 

#10064) and VITAS (CON #10065) make similar claims concerning 

rural area access issues in the hospice service area. 

Compassionate Care is more specific than any co-batched applicant 

regarding the three planned locations of its hospice offices (Duval, Clay 

and St. Johns Counties). The applicant conditions for these locations, by 

zip code. 


HealthCare of Central Florida (CON #10062) contends that in addition 

to the Agency-defined need for an additional hospice program in Hospice 

Service Area 4A, there are “special and not normal” circumstances that 

warrant the approval of another hospice program. The applicant states 

the following are “special and not normal” circumstances: 

(a) Hospice Service Area 4A consistently being underserved by existing 

hospices in light of utilization rates consistently lower than the 

Florida average hospice utilization rate; 

(b) The consistently underserved patient group: cancer patients aged 

65 years and older; 

(c) The consistently underserved patient group: non-cancer patients 

aged 65 years and older, and 

(d) The consistently underserved patient group: non-cancer patients 

under age 65. 

38


The applicant reaches this conclusion based the following assertions. 

First, the applicant presents a Hospice Service Area 4A profile, with 

demographic data (total population, age cohort and density by county 

assessments), local area health data (total area deaths, major causes of 

death, a chronic disease three-year age-adjusted mortality rate 

assessment, county death data comparisons), limitations of the current 

hospice system (underserved residents and underserved patient groups 

by age and diagnosis). Second, the applicant presents a discussion of 

the rationale behind the project, with an explanation of the applicant‟s 

quality and experience. Third, the applicant presents a quantitative need 

argument and a market forecast. These conclusions are discussed 

briefly below. 

Odyssey uses the Agency‟s „Population Estimates‟ September 2008 

publication which indicates that Hospice Service Area 4A‟s total 

population is projected to increase from 1,389,435 in 2009 to 1,460,081 

by 2012, an increase of 70,646 residents. This is an increase of about 

5.1 percent compared to the state‟s projected population growth of about 

4.9 percent. The service area‟s age 65 and over population is projected to 

increase from 167,735 in 2009 to 192,273 in 2012, an increase of 24,538 

residents or about 14.6 percent compared to 9.6 percent for the state. 

Hospice Service Area 4A by County 

Land Area & Population Density 

County Land Area (Square Miles) Population Per Square Mile 

Baker 585.21 38 

Clay 601.11 234.4 

Duval 773.67 1006.3 

Nassau 651.55 88.4 

St. Johns 609.01 202.2 

Florida Total 53,926.82 296.4 

Source: CON Application #10062 from U.S. Census Bureau, 2000 Census. 

The applicant shows population density, by each Hospice Service Area 4A 

county, is as follows, from most to least dense: Duval; Clay; St. Johns; 

Nassau and Baker. The Population Density included in Agency‟s 

Hospital Beds & Services publication of July 2009, shows the same order 

with increased population density for July 2009. 

39


POPULATION DENSITY 

Hospice Service Area 4A Counties 

July 

July 2009 

Square 2009 Population 

County Miles Population Density 

Baker 585 26,179 44.73 

Clay 601 192,458 320.18 

Duval 774 916,153 1,184.12 

Nassau 652 71,504 109.74 

St. Johns 609 183,141 300.72 

State Total 53,927 19,115,269 354.46 

Source: Agency for Health Care Administration Hospital Beds & Services – 

July 2009 Batching Cycle. 

Odyssey states that it has extensive experience in providing hospice 

services in rural areas and provides a detailed discussion of their 

Charleston, South Carolina; Temple, Texas and Savannah, Georgia 

services to residents in rural areas. Odyssey concludes that it is 

prepared to address similar rural challenges in Baker and Nassau 

Counties. The applicant conditions to have satellite offices in Nassau 

County by the end of year two of operation and Clay County to serve 

Baker County by the end of year one of operation. The applicant 

contends this will offer a measure of convenience and efficiency for 

Odyssey staff and also provide a means to offer enhanced educational 

opportunities for residents to be aware of hospice within the community. 

Concerning local area health data, the applicant notes rising service area 

death rates for all causes from 2004 through 2008, with a death rate rise 

of 6.2 percent compared to a statewide death rate of 1.3 percent. The 

applicant further notes that while cancer and heart disease accounted 

for approximately 60 percent of 2008 deaths in the hospice service area, 

this leaves an array of other life-limiting and terminal diagnoses that a 

hospice must be prepared to address. The applicant believes its 

experience especially qualifies it to meet the needs of patients with 

traditional and non-traditional diagnoses. The applicant assesses the 

three-year age-adjusted mortality rates, by various chronic disease 

categories, from 2006 through 2008, and also just for the year 2008, in 

attempting to anticipate likely causes of death in each of the counties 

within the hospice service area. 

The applicant shows that for the October 2009 Batching Cycle, Hospice 

Service Area 4A had the next to lowest hospice penetration rate of any of 

the 27 hospice service areas statewide. The applicant also shows that 

hospice penetration in 4A has been persistently below the state hospice 

40


penetration rate for each batching period since April 2004. Odyssey 

compares the state penetration rate with Hospice Service Area 4A‟s to 

demonstrate that the patient groups that are underserved include cancer 

patients aged 65 years and older, non-cancer patients under age 65 and 

non-cancer patients age 65 and older. 

With regard to the applicant‟s proposed service to under-served patients 

as a “special and not normal” circumstance, Odyssey described its 

CareBeyond Program, which includes specialized hospice protocols 

unique to specific diseases including cancer, COPD, congestive heart 

failure and dementia. The applicant conditions for the implementation of 

this specific protocol system. The applicant describes in detail how 

CareBeyond applies to a cancer, COPD, congestive heart failure and 

dementia diagnosis. 

The applicant also indicates that interviews in the hospice service area 

revealed other needs, including: local interest in psycho-social support 

and hospice care in nursing homes, hospice education at ALFs, 

education on end-of-life decisions, continuous care when death is 

imminent, and patient admission with a physician order within three 

hours (24 hours a day, seven days a week). The applicant does not 

condition for admission to the program within three hours of a physician 

order. 

With regard to the applicant‟s quantitative need and a market forecast, 

the applicant utilizes three methods to assess quantitative admission 

estimates – the Agency‟s need projection, the Agency‟s need projection 

modified using the 4A admission rate for cancer patients under age 65 

and a third approach based on a continuation of Service Area 4A‟s 

historic growth rates in hospice admissions, population growth and aging 

population. The applicant states that these factors support a future 

overall increase in hospice penetration. 

Seasons Palliative Care of Florida, Inc. (CON #10063), indicates that 

Marcia Norman, President and Founder of the parent organization, 

traveled on two occasions to Florida and spent several days each trip 

meeting with Service Area 4A hospital discharge planners, hospital 

administrators, nursing home operators, directors of assisted living 

facilities, physicians, providers, and community residents. The applicant 

indicates that from these meetings, Ms. Norman found several benefits 

that form the objective for their proposal. These include providing 

greater numbers of access points to increase hospice utilization, make 

available specialized programs with proven benefits to hospice patients 

such as „Touch for All Seasons‟, „Kangaroo Kids‟ and „Tender Legal Care‟. 

Seasons will also provide a 24-7 call center to ensure residents‟ needs 

41


are met and provide area providers, such as nursing homes, assisted 

living facilities and senior centers access to resources that develop longterm 

relationships with the hospice teams. They will also provide 

educational and promotional events to make hospice care more visible as 

part of the service area‟s health care delivery system. Seasons indicates 

a need to involve other providers in the provision of hospice inpatient 

care. 

Seasons provides a detailed description of the service area 4A population 

by county for 2008 and 2007 deaths, including projected population 

estimates through 2012. The applicant indicates that its analysis shows 

the service area‟s „Cancer over 65‟ and „Other over 65‟ groups are 

underserved compared to the state average. Seasons also finds that Clay 

County residents aged 65 years and older have a higher in-hospital death 

rate at 12.6 per thousand compared to the service area average at 11.5 

per 1,000 aged 65 years and older. The applicant notes that Baker 

County at 13.5 and Duval County at 12.1 per thousand population age 

65 and older also have a higher in-hospital death rate per thousand than 

the service area. However, Baker County had only 54 deaths and is 

located at the western border of the service area and Duval has three 

existing hospice offices, so the applicant rules them out as a location for 

an office. Clay County residents‟ death rate for eight illness categories is 

higher than Nassau and St. Johns‟ Counties and higher than the state‟s 

rates in seven of the eight. These factors indicate to the applicant that 

Clay County is underserved, thus Seasons plans to locate in Clay 

County, in or near Orange Park. 

Seasons next discussed Service Area 4A population projections 

indicating that from 2009 to 2012 the population age 65 and over will 

increase from 165,282 to 187,423 or by 13.4 percent, compared to the 

total population increase from 1,383,913 in 2009 to 1,446,196 or by 4.5 

percent. By year two (ending in December 2012) Seasons projects 615 

admissions, with 35,690 patient days and an average length of stay 

(ALOS) of 56 days. This actually computes to a 58 day ALOS. The 

applicant expects to capture a six percent market share by year one 

(ending December 2011) and a nine percent market share by year two 

(ending December 2012). Seasons also provides a detailed description of 

Florida start up hospice admissions in support of its projections. The 

applicant‟s projections appear to be somewhat reasonable based on the 

market shares captured by other new hospice programs that became the 

fourth hospice in the service area and began operations during and after 

42


February 2005. However, the applicant concedes that initial market 

share capture rates can vary widely but states its projections are also 

based on Season‟s national experience. 

Seasons places emphasis on its accreditation with the Joint Commission 

and conditions to have this program so certified. They also discussed the 

existing 4A hospice providers and competitors, noting that none have 

Joint Commission accreditation. Seasons notes that Haven Hospice has 

Community Health Accreditation Program (CHAP) and Accreditation 

Commission on Health Care (ACHC) accreditation 6 . The applicant 

indicates that it has Joint Commission accreditation on hospices in 

seven of the 10 states it operates in and is in the process of obtaining 

accreditation in the remaining three states. This compares to VITAS with 

five programs in Pennsylvania and two in Texas, Odyssey with one in 

Rhode Island and one in Texas; Compassionate Care with 12 programs 

(including home health agencies, one in Fort Lauderdale, Florida) and 

United Hospice with one in New York. VITAS has CHAP core hospice 

accreditation for its Miami hospice; Odyssey has two - Oklahoma City 

and Dallas; and Compassionate Care has 15 core hospice accreditations, 

none in Florida. The applicant states that none of the competing 

hospices have ACHC accreditation. 

United Hospice of Florida, Inc. (CON #10064) compares Hospice 

Service Area 4A‟s penetration rate with the state average which shows 

that overall Service Area 4 was 7.7 percent below the state average. 

United contends that non-cancer patients of all ages appear to be 

particularly underserved. Non-cancer patients under age 65 and the age 

65 and over cancer cohorts are each 1.3 percent and the 65 and over 

non-cancer cohort 8.3 percent below the state average. According to the 

applicant, 73.3 percent of United‟s patients have a non-cancer diagnosis 

and its extensive experience along with its corporate resources give 

United Hospice an advantage to meet the hospice need of the area. The 

applicant contends that the following populations are underserved: 

African Americans, the homeless, terminally ill residents in rural outlying 

areas, patients needing continuous care, and patients with a terminally 

ill non-cancer diagnosis. 

Concerning African Americans, the applicant provides a December 2009 

18-page article from the Journal of Pain, Vol. 10, No. 12 (CON 

Application #10064, Tab 15-Racial and Ethnic Disparities in Pain: 

Causes of Unequal Care) that explores disparities in palliative care and 

overall hospice service nationwide. The applicant indicates that eight 

6 Accreditation status for competitors and existing Service Area 4A providers was confirmed with the 

Agency‟s Licensed Home Health Programs Unit. 

43


professional staff of United spent three weeks in the service area meeting 

with community leaders and others. They conclude that greater hospice 

education and outreach is needed in the local African American 

community. The applicant further notes that in 2008, Duval County 

acute care hospitals discharged African American patients to hospice at a 

disproportionately lower rate (0.9 percent) compared to all other patients 

(1.8 percent). The applicant states that had African Americans been 

discharged to hospice care at the same rate as non-African Americans, 

an additional 305 African Americans would have been so discharged. 

United also notes that within a five-mile radius of four major Duval 

County hospitals, there is an African American population ranging from 

29 to 60 percent. The applicant also provides a comparison of these 

facilities African American discharges to their overall discharges and 

discharges to hospice. United states that in communities in which the 

African-American population exceeds 30 percent of total population, as is 

the case in Duval County, UHS patient days provided to African 

Americans exceed 46 percent of total patient days. For the 12 months 

ending October 31, 2009, more than 26 percent of UHS‟ total patient 

days were provided to African-Americans. The applicant indicates that 

16 of its 26 hospice programs provided 26 percent or more and five 

programs provided over 40 percent of their total admissions to African 

Americans. The applicant indicates this reflects its success in outreach 

concerning the African American population and expects similar efforts 

and results in reaching the African American community in the area, if 

the project is approved. United concludes this discussion by restating its 

proposed condition (#2) to implement and maintain an African-American 

Outreach Program and provides a list of groups and individuals that it 

will contact. Some of these include: local NAACP branches, Jacksonville 

Urban League, Black Chamber of Commerce, Jacksonville Mayor‟s Office, 

State Senator Tony Hill, Sr., and State Representatives Mia Jones and 

Audrey Gibson. There were no support letters from any of these entities 

or individuals. 

United states that the Northeast Florida Center for Community Initiatives 

at the University of North Florida compiles an annual report of the Duval, 

Clay and Nassau Counties‟ homeless population for the Emergency 

Services and Homeless Coalition of Jacksonville, Inc. (ESHC) 7 . This 

report indicates that there were 18,393 homeless adults and children 

spread among the three counties in 2008, representing a 7.7 percent 

increase over the prior year. Of the 18,393 homeless individuals, 18,088 

7 The ESHC website indicates that it has 54 member agencies and is committed to coordinating efforts 

to raise, distribute and manage resources for preventing and ending homelessness. ESHC is the lead 

agency for Duval, Clay, Nassau and Baker Counties. 

44


were in Duval County. The application includes letters of support from 

representatives of the ESHC, the Medical Home for Homeless Children 

Project, Family Promise of Jacksonville, and the I.M. Sulzbacher Center 

for the Homeless. The applicant states it is a corporate member of the 

Homeless Coalition of Jacksonville, Inc. and has attended regular 

monthly membership meetings to stay current with relevant topics 

affecting the homeless in the area. United concludes by restating its 

condition #3 specific to the homeless which includes a list of the 

following shelters: City Rescue Mission, Hubbard House, the Salvation 

Army, the Sulzbacher Center, and Trinity Rescue Mission. As noted 

above the applicant has a letter of support from the Sulzbacher Center. 

Concerning the rural population, the applicant focuses primarily on 

Baker County as particularly underserved. Baker County is in the St. 

Johns River Rural Health Network and is a designated Health 

Professional Shortage Area and Medically Underserved Area by the 

Shortage Designation Branch, Bureau of Health Professions, Health 

Resources and Services Administration, US Department of Health and 

Human Services. Both these designations are verified by the Agency 8 . 

Letters of support from this area are included in the application. The 

applicant believes its experience is well suited to reach this underserved 

rural area indicating that nearly 50 percent of its hospice programs are 

located in rural areas of Georgia, South Carolina and North Carolina. 

The applicant indicates this includes 11 of UHS‟ 25 programs that are 

considered rural by federal guidelines or have been considered rural in 

previous years. United indicates that UHS has three other programs that 

have service areas that are largely rural but are considered to be part of a 

metropolitan statistical area. UHS states that it will use the National 

Hospice and Palliative Care Organization‟s recommendations for rural 

hospice care specific to hiring nurses for on-call coverage, joint nurse 

and social work visits and have a full-time staff position to assist in 

promoting hospice services in the area. The applicant conditions its 

proposal to the opening of an office in Baker County immediately upon 

project approval and an office in Nassau County by the end of its second 

year. It also conditions it will become a member of and join the St. 

Johns River Rural Health Network to address rural hospice concerns. 

Concerning patients in need of continuous care, the applicant notes a 

statewide average of 2.4 percent for continuous care days as a percent of 

total days in 2008, compared to the Hospice Service Area 4A average of 

0.3 percent continuous care days. United indicates that the 2008 

Medicare Cost Report and NHA Analysis data shows continuous care 

8 http://hpsafind.hrsa.gov/HPSASearch.aspx. The Agency notes the Baker County, Florida Primary 

Care HPSA designation is current and the MUA designation date was November 1, 1978. 

45


accounted for 0.3 percent patient days at Community Hospice and Haven 

Hospice, and 0.2 percent of Heartland‟s patient days. The applicant 

contends that the limited availability of continuous care in Service Area 4 

discourages the ability to maintain the patient‟s home as the primary 

focus of care. United conditions that 2.5 percent of its total patient days 

will be continuous care patient days by the end of year two. Only cobatched 

applicant, VITAS Healthcare Corporation of Florida, conditions 

for a higher percentage of continuous care days by the end of year two (at 

3.0 percent). 

Concerning non-cancer patients, the applicant states that of the 925 

projected „gap‟ in hospice admissions for the January 2011 batching 

cycle, 82 percent will be non-cancer. The applicant reports it has the 

most experience and greatest concentration of patients within the noncancer 

disease category. United indicates that 73.3 percent of its total 

admissions during the 12-month period ending October 31, 2009, were 

non-cancer diagnoses. The applicant states that United‟s non-cancer 

admissions were as high as 87.5 percent in some programs. The 

applicant previously mentioned its CareBeyond Program, in which 

disease-specific hospice care is applied to applicable patients, depending 

on the particular diagnosis. 

United provides a brief description of existing hospice programs and 

likely impact in the area, if the project is approved. Existing programs 

are stated to provide care primarily to the Caucasian demographic, 

accounting for at least some of the African American hospice disparity in 

the area. Due to the documented published need, the applicant 

anticipates no negative impact upon project approval and the Agency 

notes no letters of opposition were received from any of the existing 

hospice programs in Hospice Service Area 4A. 

As part of its in-depth marketing field survey and analysis efforts, the 

applicant states that United Hospice conducted a town hall meeting at 

the Crown Plaza Hotel in Jacksonville (Duval County), on December 15, 

2009. The applicant provides the town hall timely invitation 

announcement letter and a signed affidavit that notice of the forum was 

published in The Florida Times-Union for three consecutive days. 

Finally, United Hospice provides a discussion of why it should be 

approved over the other 4A competitors in this batching cycle. 

46


VITAS Healthcare Corporation of Florida (CON #10065) indicates that 

based on its analysis of the Medicare Hospice Standard Analytical File 

Limited Data Set and the Denominator File for CY 2007 (issued by the 

Centers for Medicare and Medicaid Services) and meetings with local 

leaders, the underserved populations in Hospice Service Area 4A are 

African-American patients and non-cancer patients 65 years of age and 

older. The applicant‟s justification to note these populations as 

underserved is briefly described below. 

VITAS indicates that its analysis revealed that only 449 of service area 

4A‟s African-American Medicare deaths were admitted to the existing 

hospices during calendar year 2007. This results in an African-American 

admission rate of 43 percent. The applicant indicates that based on the 

state‟s average hospice penetration rate for African-Americans of 51 

percent, an additional 79 African American patients should have received 

hospice care. VITAS provides a detailed description of its efforts to 

educate and reach into the African-American community. The 

application‟s Tab 14 provided additional information on VITAS corporate 

partnerships and its extensive out-reach programs to African-Americans 

and Hispanics. 

The applicant provides the following table to support its contention that 

VITAS is doing a better job of serving African-Americans than the existing 

Service Area 4A providers and Odyssey. 

Percentage of Hospice Admissions Who Were African-American in 2007 

Selected Florida Counties & Hospice Organizations 

Hospice Hospice Percent Resident Percent Percent Difference 

Community 12.3% 12.1% 1.7% 

Haven 9.5% 11.2% -15.2% 

Heartland 5.6% 12.1% -53.7% 

Odyssey 6.0% 8.5% -29.4% 

VITAS 10.1% 7.1% 42.3% 

Source: CON Application #10065, page 51. 

Note: Hospice Percent is the percent of the hospice’s patients who were African American. 

Resident Percent is percent of all hospice patients in these areas who were African Americans. 

As the table above shows, 10.1 percent of VITAS admissions were African 

American. African Americans were 7.1 percent of all hospice admissions 

in the service area resulting in a 3.0 percent difference. The VITAS 

percentage is 42.2 percent higher (10.1 percent/7.1percent) than the 

resident percentage. Should the applicant‟s numerous qualifying 

statements (See CON #10065, page 51 and Tab 13) to its analysis be 

accurate, it appears that VITAS is doing a better job of serving African 

Americans than the existing Service Area 4A providers and Odyssey. 

47


VITAS concludes this portion of its need discussion by citing its support 

letters from individuals and organizations which indicate that the African 

American community in Service Area 4A is underserved and approval of 

the applicant will enhance access. 

VITAS provided a chart showing 4A Need by Category contained in the 

Agency‟s hospice need calculation on page 52 of their application. The 

applicant compares projected need based on the state average to the 4A 

service area with the state projections by diagnostic category and age (i.e. 

Cancer age under 65 and 65 and over and „All Other‟ age under 65 and 

65 and over) they conclude that the service area is underserved 

especially in the age 65 and over „Other‟ category. The applicant 

indicates that with 679 of the projected 925 incremental visits, the „other‟ 

age 65 and over category is 73.4 percent of the total projected need. 

The applicant provides the following table to support its contention that 

VITAS is doing a better job of serving non-cancer patients than the 

existing Service Area 4A providers and also exceeds the state average. 

Experience with Non-Cancer Patients 

12 Month Periods Ending June 30 

2007 2008 2009 

Existing 4A Providers 59.22% 59.30% 60.80% 

VITAS Florida Hospices 67.31% 66.83% 68.06% 

State of Florida 63.02% 64.02% 64.60% 

Source: CON Application #10065, page 53. 

According to the applicant, for the 12-month period ending June 30, 

2009, 68.1 percent of VITAS‟ Florida hospice patients had a non-cancer 

diagnosis, 12 percent higher than existing Hospice Service Area 4A 

hospice providers. The applicant also discussed causes of death in the 

hospice service area in years 2006 through 2008 and states that VITAS 

will develop programs for patients with heart disease, Alzheimer‟s 

disease, HIV/AIDS and pulmonary conditions. The applicant references 

specialized VITAS programs for specific disease categories such as COPD, 

Alzheimer‟s, heart disease, HIV/AIDS and diabetes. VITAS also indicates 

that in many cases patients age 65 and older with a non-cancer 

diagnosis are already in nursing homes when hospice services commence 

and that VITAS has already worked with nursing homes in Florida to 

address this circumstance. VITAS has the most letters of commitment to 

enter into appropriate arrangements for inpatient hospice beds, should 

the project be approved. 

48

2. Agency Rule Criteria and Preferences 


a. Rule 59C-1.0355(4)(e) Florida Administrative Code. Preferences for 

a New Hospice Program. The Agency shall give preference to an 

applicant meeting one or more of the criteria specified in the below 

listed subparagraphs: 

(1) Preference shall be given to an applicant who has a 

commitment to serve populations with unmet needs. 

Compassionate Care Hospice of Florida, Inc. (CON #10061) 

agrees to serve any and all populations in Hospice Service Area 4A 

with unmet hospice needs. The applicant indicates the areas of 

highest unmet hospice need in the area are as follow: 

• all ages in all diagnostic groups; 

• one new hospice office, upon initial operation, by designated zip 

code, in the following counties – Duval, Clay and St. Johns (this 

is conditioned by the applicant); and 

• one dedicated community relations coordinator (this is 

conditioned by the applicant) to support and coordinate with 

non-health care provider key constituency groups, e.g., 

churches, inner city organizations, support groups, cancer 

society, homeless organizations, low income housing, etc. 


HealthCare of Central Florida (CON #10062) states there are 

“special and not normal” circumstances that warrant approval of 

another hospice program in the area. These “special and not 

normal” circumstances are identified by the applicant as follows: 

• the consistently underserved patient group – cancer patients 65 

years of age and older; 

• the consistently underserved patient group – non-cancer 

patients 65 years of age and older; and 

• the consistently underserved group – non-cancer patients under 

age 65. 

Seasons Palliative Care of Florida, Inc. (CON #10063) states 

that no definition exists for “unmet needs” but does make reference 

to Chapter 59C-1.008(2)(e), Florida Administrative Code 9 . The 

applicant notes that cancer patients age 65 and older in the service 

9 Chapter 59C-1.008(2)(e)3, “The existence of unmet need will not be based solely on the absence of a 

health service, health care facility, or beds in the district, subdistrict, region or proposed service area”. 

49


area for the 12-month period ending June 30, 2009 had a 0.3 

percent rate of under service compared to the statewide average. 

For the same period, non-cancer patients age 65 and older in the 

service area had a 6.8 percent rate of under service. The applicant 

indicates it will serve both the underserved population as well as 

categories that were not shown as underserved. The applicant 

expects to serve 402 hospice patients in year one and 615 in year 

two (CON Application #10063, page #2-4, Table 2-4). 

United Hospice of Florida, Inc. (CON #10064) indicates that 82 

percent of the unmet need in the hospice service area is in the 

non-cancer category and that in several of its programs, 85.2 

percent of United Hospice‟s admissions are non-cancer patients. 

United states that the following groups are underserved in Hospice 

Service Area 4A regarding hospice care: 

• the Africa American population; 

• the homeless population; 

• the rural population; 

• patients in need of continuous care; and 

• terminally ill non-cancer patients. 

The applicant proposes conditions to address the African- 

American, homeless and rural populations (particularly Baker and 

Nassau Counties and membership in the St. Johns Rural Health 

Network). 

VITAS Healthcare Corporation of Florida (CON #10065) states 

that the greatest unmet need for hospice service in the area is 

among the following populations: 

• African-American population; and 

• Non-cancer patients (particularly those age 65 and older). 

The applicant notes that 679 of the 925 unmet hospice need in the 

area (or about 74 percent of the unmet need) was in terminal noncancer 

patients age 65 and older. Also, they estimate 79 African- 

Americans in the area had unmet hospice need. 

(2) Preference shall be given to an applicant who proposes to 

provide the inpatient care component of the hospice program 

through contractual arrangements with existing health care 

facilities, unless the applicant demonstrates a more costefficient 

alternative. 

50


Compassionate Care Hospice of Florida, Inc. (CON #10061) has 

two acute care hospital letters of willingness to provide inpatient 

beds for hospice services – one is from Memorial Hospital- 

Jacksonville (Duval County) and one is from Orange Park Medical 

Center (Clay County). The applicant states that it will have 

contracts in place in each of Hospice Service Area 4A‟s five 

counties; however, this is not conditioned by the applicant. 


HealthCare of Central Florida (CON #10062) does not include an 

acute care hospital or a skilled nursing facility commitment letter 

to enter into an arrangement for inpatient beds, though it states it 

is in ongoing discussions to obtain memoranda of understanding 

for general inpatient contracts with potential provider partners in 

the service area. To support its history in obtaining such 

agreements, the applicant provides sample provider agreements 

and a list of Volusia County and Miami-Dade County like contract 

agreements (CON Application #10062, Appendix N). 

Seasons Palliative Care of Florida, Inc. (CON #10063) has a 

letter of willingness to provide inpatient beds for hospice services 

from Kindred Hospital-North Florida, a long-term care hospital 

located in Clay County. The applicant indicates this would 

promote access to residents of Clay and St. Johns Counties. The 

applicant also proposes to provide inpatient care through 

contractual agreements with area hospitals and nursing homes. 

United Hospice of Florida, Inc. (CON #10064) states 

commitments to enter into contractual agreements for inpatient 

services are in discussion, pending CON approval with the 

following providers: Memorial Hospital-Jacksonville (Duval 

County), Kindred Hospital North Florida (Clay County), River 

Pointe Behavioral Health Center (Duval County), Wekiva Springs 

Center for Women (Duval County), Life Care Center of Orange Park 

(Clay County), Quality Health of Fernandina Beach (Nassau 

County), W. Frank Wells Nursing Center (Baker County), Moultrie 

Creek Nursing & Rehabilitation Center (St. Johns County), and 

Ponce de Leon Care Center (St. Johns County). 

The following four facilities make specific reference to entering into 

contractual agreements with United for inpatient services to 

hospice patients, should the applicant be approved: River Point 

Behavioral Health Center and Wekiva Springs Center for Women 

(Duval County inpatient psychiatric hospitals) and two nursing 

homes, Life Care Center of Orange Park (Clay County) and Quality 

51


Health of Fernandina Beach (Nassau County). Memorial Hospital- 

Jacksonville states that they would be willing to enter into an 

agreement with United Hospice should they begin delivering 

services here and would be very interested in partnering with 

United to enhance the health care of local residents. Kindred 

Hospital North Florida and W. Frank Wells Nursing Center state 

that they would be “willing to partner with” or “work cooperatively 

with” United to provide inpatient hospice care. The support letters 

from Moultrie Creek Nursing & Rehabilitation Center and Ponce de 

Leon Care Center state they are willing to “use them (United) to 

provide inpatient care to our residents”. 

VITAS Healthcare Corporation of Florida (CON #10065) has six 

letters of support that state willingness to enter into an inpatient 

arrangement in providing inpatient beds for hospice services. They 

are all SNF providers, two being in Clay County (The Terrace at 

Fleming Island and Governor‟s Creek Health and Rehabilitation 

Center) and the remaining four being located in Duval County 

(Fleet Landing, Harts Harbor Health Care Center, San Jose Health 

and Rehabilitation Center and West Jacksonville Health and 

Rehabilitation Center). Fleet Landing and The Terrace at Fleming 

Island indicate that they would be willing to consider entering into 

an inpatient agreement with VITAS. None of the nursing homes 

indicate a specific number of beds they would be willing to contract 

out to VITAS. 

(3) Preference shall be given to an applicant who has a 

commitment to serve patients who do not have primary 

caregivers at home; the homeless; and patients with AIDS. 


states that they are committed to serving patients who do not have 

primary caregivers at home, the homeless, and patients with AIDS. 

The applicant states that as of December 15, 2009, 7.7 percent of 

the patients it served lived alone and 2.9 percent lived with a 

“compromised caregiver”. The applicant indicates that it does not 

require that a patient have a caregiver in the home to be part of 

their program. In addition, the applicant states it has provided 

care to individuals in boarding homes, homeless shelters, 

psychiatric centers, and correctional facilities. The applicant 

states that it serves all patients and, in addition to those who live 

alone, this includes transients, and those who have AIDS, or are 

homeless. The applicant states that if a homeless patient desiring 

Compassionate Care Hospice care is discharged from a hospital 

52


and has nowhere to go, Compassionate Care will place them in an 

inpatient unit and apply for Medicaid. Once the patient qualifies 

and receives Medicaid, they will be placed into a long-term care 

environment in which hospice care can still be provided as long as 

the patient requires such care. 


HealthCare of Central Florida (CON #10062) states that it 

accepts all patients who meet admission criteria, including 

patients who do not have a primary care giver at home, as well as 

the homeless and patients with AIDS. The applicant explains that 

an Odyssey nurse will coordinate appropriate action and 

placement with the rest of the interdisciplinary team and hospice 

physician or attending physician. Odyssey describes numerous 

mechanisms to address admissions and placement (CON 

Application #10062, page #83 and Appendix F - Policies & 

Procedures Matrix). 

Seasons Palliative Care of Florida, Inc. (CON #10063) includes, 

as part of its admission policy 10 , that Seasons does not require a 

patient to have a primary caregiver. In the absence of a caregiver, 

the applicant states it begins discussion upon admission with the 

patient to make plans for his/her care when he/she is no longer 

able to make decisions. Seasons also states that as part of this 

policy, admission is limited to those patients who have a family 

member or designated person who is able and willing to assume 

the role of caregiver. The applicant states it will treat persons with 

AIDS and that Hospice Service Area 4A has a higher average AIDS 

rate (26.1 percent) and AIDS death rate (9.8 percent) than the state 

average AIDS rate (23.7 percent) and statewide death rate (8.4 

percent) for the three-year period ending 2008 [CON Application 

#10063, page #2-8, Table 2-5]. 

United Hospice of Florida, Inc. (CON #10064) commits to 

serving those who do not have a primary caregiver, the homeless 

and those with AIDS. United, more than any other co-batched 

applicant, provides substantial letters of support from 

organizations that serve the homeless and conditions their 

application to serve selected homeless shelter facilities and 

10 CON Application #10063, page #2-6, Policy #7. 

53


organizations. The applicant states it will request a caregiver upon 

admission and if a caregiver is not identified, they will develop, as 

part of the plan of care, a means by which daily care and safety 

needs of the patient will be met. It is further stated the applicant 

will seek to assist in developing a caregiver network. If a caregiver 

arrangement cannot be established in the least restrictive 

environment practical, the applicant reports it may recommend 

placement in an ALF or SNF, in which residential care would be 

available. The applicant also states it is aware of the higher AIDS 

rate in the hospice service area, indicating that some of those that 

are homeless are AIDS patients. The applicant indicates that for 

the 12-month period ending October 31, 2009, 1.2 percent of all 

United Hospice admissions were AIDS related patients. 

VITAS Healthcare Corporation of Florida (CON #10065) states 

that if a patient lives alone and a caregiver is not nearby and able 

to care for the patient, VITAS will assist the patient in developing 

an applicable network. VITAS will also recommend qualified adult 

sitter services, if applicable and provided a financial hardship is 

not created. A 24/7 phone service is stated as an option for those 

who do not have such service. According to the applicant, nursing 

home and ALF options will be considered for the homeless. VITAS 

also indicates an awareness of AIDS patients and HIV related 

deaths in the area, with 106 AIDS related deaths in 2006 and 111 

such deaths in 2008 in Hospice Service Area 4A. If approved, the 

applicant indicates VITAS will institute a program to assure 

terminally ill patients with HIV have access to hospice care. 

(4) In the case of proposals for a hospice service area comprised 

of three or more counties; preference shall be given to an 

applicant who has a commitment to establish a physical 

presence in an underserved county or counties. 

Hospice Service Area 4A consists of five counties (Baker, Clay, 

Duval, Nassau and St. Johns. Therefore, this criterion is 

applicable. The chart below indicates the number of operational 

hospice locations in the service area, by county. 

54


Hospice Service Area 4A 

Operational Hospice Office Locations 

By Provider and County as of January 11, 2010 

Community Hospice 

of Northeast 

Florida, Inc. 

55 

Heartland Home 

Health Care and 

Hospice 

County/Provider 

Haven 

Hospice* 

Baker 0 0 0 0 

Clay 0 0 0 0 

Duval 1 1 1 3 

Nassau 1 0 0 1 

St. Johns 1 1 0 2 

Total 3 2 1 6 

Source: Agency for Health Care Administration Home Care Unit Licensure Records. 

*Haven Hospice‟s main office is in Alachua County. Community Hospice deleted its Clay office 

effective 8/1/09 and has three inpatient hospice facilities in Duval County. 

Total 

Compassionate Care Hospice of Florida, Inc. (CON #10061) is 

the only co-batched applicant to condition, by zip code, for three 

office locations in the hospice service area upon commencement of 

services. Those counties are as follows: Clay, Duval and St. Johns. 

The applicant also states that if demand requires an office in 

Nassau County and/or Baker County, an office will be opened in 

either or both counties; however, this is not conditioned. 


HealthCare of Central Florida (CON #10062) conditions for the 

immediate development of a main office in Duval County and two 

satellite offices – one in Clay County by the end of year one and 

one in Nassau County by the end of year two. 

Seasons Palliative Care of Florida, Inc. (CON #10063) 

conditions to locate a main office in Clay County. This applicant 

contends that Clay County offers the best location for an office 

based on in-hospital death rates in the service area. The applicant 

notes that Baker, Clay and Duval Counties have higher in-hospital 

death rates among the 65 years of age and older population, per 

1,000 residents in calendar year 2008 (CON Application #10063, 

page #2-9, Table 2-6). Though the applicant notes that the higher 

death rate in this population is in Baker County (at 13.5 percent 

for elderly residents per 1,000 population in calendar year 2008), 

the relatively low mortality count and the county‟s location 

(tangent to the western border of Duval County) rules Baker 

County out as a “good location” from which to serve the area. 

Seasons finds that Duval County is well represented concerning 

office locations, considering existing hospices in the area. Seasons 

also considers, in selecting Clay County for an office location, that 

after ruling out Baker County and Duval County, among the 

remaining three counties, Clay County residents have similar


death rates among like diseases in both Nassau and St. Johns 

Counties (CON Application #10063, page #2-10, Table 2-7). Again, 

the applicant finds Clay County is indicated for an office location 

and believes access to the remaining four counties can occur. 

United Hospice of Florida, Inc. (CON #10064) notes that 

utilizing the Agency‟s population estimates and projections 

publication (dated September 2009) Baker County‟s population 

represents only 2.0 percent of Hospice Service Area 4A and only 

2.2 percent of the deaths in the hospice area. However, the 

applicant also notes that none of the existing hospices have an 

office located in Baker County and contends that Baker County 

residents lack accessible hospice services. The applicant 

conditions that it will open a main office in the City of Jacksonville 

(Duval County) and two satellite offices – one in Baker County 

immediately upon licensure and a second one in Nassau County by 

the end of their second year of operation. 

VITAS Healthcare Corporation of Florida (CON #10065) states it 

conditions to have satellite offices in Baker and Nassau Counties 

during the first year of operation. It also states on page 17 of the 

application that it conditions to establish a main office in Duval 

County. 

(5) Preference shall be given to an applicant who proposes to 

provide services that are not specifically covered by private 

insurance, Medicaid, or Medicare. 


states it currently provides services that are not covered by private 

insurance, Medicaid, or Medicare, and will continue to do so in the 

program proposed for Hospice Service Area 4A. Compassionate 

Care states it provides services needed to all patients regardless of 

payer status, and in many instances regardless of legal status. 

Compassionate Care states that in its most recent year (exact year 

is not stated) the proportion of care delivered to patients who were 

unable to pay was 2.6 percent. 

In addition to providing its full-range of services to patients not 

covered by private insurance, Medicaid or Medicare, the applicant 

states it offers services that are not included in the range of 

services typically reimbursed by these programs. These services 

include: 

56


Bereavement – Bereavement counselors are stated to assist 

grieving families in finding healthy paths to healing. These 

counselors are said to be available to family members for up to 

15 months following the death of the hospice patient and 

volunteers are said to be trained to understand healthy 

bereavement care, to recognize abnormal patterns of grief, and 

to provide appropriate support and encouragement through the 

grieving process. Compassionate Care also proposes that it will 

provide age-specific grief group counseling, through programs 

such as the Rainbow Program, a pediatric bereavement 

program, as well as individualized one-on-one counseling. The 

applicant provides its bereavement policy for Agency review 

(CON Application #10061, Appendix Q-Bereavement 

Services/Policy No. 2003.7). 

• Cardiac Connection Program – This program is designed for 

those with end-stage heart failure and advanced congestive 

heart failure, which may include continuous care (CON 

Application #10061, Appendix B and Appendix R). 

• Promise Program – Promise is an acronym for “Providing Renal 

Options: More Individualized Support and Education”. 

Specifics are provided by the applicant (CON Application 

#10061, Appendix B). 

• Compassionate Care Hospice Foundation Activities – 

Compassionate Care Hospice Foundation, Inc. is stated to be a 

non-profit fundraising organization affiliated with 

Compassionate Care Hospice which provides financial 

assistance to terminally ill patients and families in need. It also 

is stated to support public programs that provide the general 

public with information regarding end-of-life choices allowing 

individuals to determine and communicate their wishes and 

help their families prepare for the future. The applicant 

conditions that the Compassionate Care Hospice Foundation 

will provide assistance to needy patients and families. The 

following are stated examples of instances in which the 

Compassionate Care Hospice Foundation provided assistance to 

patients and families: 

o Rent, mortgage and utility payments are made for 

individuals and families; 

o Summer camp for an 11 year-old child whose single mother 

was terminally ill, 

57


o A special therapeutic pillow to help ease pain for a terminally 

ill child, 

o Covering the cost of dinner and a babysitter for parents who 

were caring for a terminally ill child and had not had any 

time together “in a very long while”, 

o Funding special projects, volunteer efforts, and educational 

programs in various communities designed to raise public 

awareness about hospice care; and 

o Providing an annual $10,000 grant toward funding 

Compassionate Courage, a program for school-aged children 

with a family member undergoing cancer treatments, 

terminal illness, or children who have experienced a loss due 

to death or changes in family structure. 

• Compassionate Courage – A program offering a safe place for 

children to express their feelings and share with others who 

have experienced similar loss. Compassionate Courage 

programs provide bereavement support groups for elementary 

and middle school children who are dealing with a significant 

loss. 

• Complementary Therapies – Complementary therapies are 

stated to be offered at no charge to hospice patients to ease pain 

and discomfort. Sample therapies include the following: 

o Songs for the Soul – Music therapists provide unique, 

relaxing music to alleviate stress, pain and discomfort, and 

to promote peace, tranquility, and relaxation. 

o Looking Great – A licensed beautician provides haircuts, 

hairstyling, and beauty tips, helping patients look and feel 

their best. 

o Therapeutic Touch – A licensed massage therapist provides a 

variety of massage techniques to reduce stress, relieve 

cramps, and improve circulation promoting comfort and an 

increased sense of well being. 

o Pet Visitor Program – Physical contact with pets has been 

shown to have a number of benefits, reducing stress and 

increasing joy and well being. To date, Compassionate Care 

has incorporated dogs, cats and rabbits in its program, to 

the delight of many patients. 

o Good Scents – An aroma therapy program. 

o Art Therapy – A program assisting patient and family 

members in creating arts and crafts projects. Using ones 

hands to create a product helps alleviate depression and 

provides a sense of connectedness and accomplishment. 

58


• Rainbow Program – This program provides support for children 

who are experiencing grief through a death or divorce in the family, 

designed to bring hope to grieving children, moving through hurt 

into healing and hope (CON Application #10061, Appendix I- 

Compassionate Care 4 Kids Materials/Pediatrics Program). 

• Comfort Corners – This is physical areas in long-term care facilities 

where a warm, home-like environment is provided for patients and 

their families. 

The applicant assures that discriminatory factors (such as race, 

ethnicity, gender, age, religious affiliation, diagnosis, financial and 

insurance status and any other factors that would have the effect 

of discriminating) will not be applied. This is conditioned. As 

stated previously, hospice programs are required by federal and 

state law to provide services to everyone requesting them and 

therefore the Agency would not place conditions on a program to 

provide legally required services such as palliative radiation and 

chemotherapy and those lacking the ability to pay. 


HealthCare of Central Florida (CON #10062) states that services 

not specifically covered by Medicaid or Medicare will be provided 

and include the following: pet, music, massage and aroma 

therapies; dialysis and palliative radiation and palliative 

chemotherapy. With the exception of dialysis, these non-covered 

services are conditioned by the applicant. It is further stated the 

hospice services will be provided to all patients regardless of their 

ability to pay and this too is conditioned. As stated previously, 

hospice programs are required by federal and state law to provide 

services to everyone requesting them and therefore the Agency 

would not place conditions on a program to provide legally required 

services such as palliative radiation and chemotherapy and those 

lacking the ability to pay. 

Seasons Palliative Care of Florida, Inc. (CON #10063) provides 

the following services not specifically covered by payers. 

• Music Therapy – every new program has a full time music 

therapist and more is added as the program grows to a census 

ratio of one music therapist to 75 enrollees. 

Seasons states that even when a person is no longer conscious 

or speaking, they can be consoled and comforted with music. 

59

11 http://www.joycesimard.com/. 


The applicant conditions that music therapy will be a standard 

core service, as prescribed in the plan of care. Some, but not all 

the planned for music therapy goals are as follows: 

reminiscence (focus on assets and positive experiences); 

identification and expression of emotions; increased 

socialization; establishment of trust and rapport; development 

of effective coping skills; mood management; a medium for 

closure and many others. 

• Pet Therapy – a specialized program within volunteer services 

that provides specialized training for volunteers with pets that 

are therapy certified. Seasons notes pet therapy will be 

included in the plan of care. The volunteer coordinator oversees 

the pet therapy program. 

• Palliative Care Program – Seasons states this program provides 

clinical support management for people living with an advanced 

illness and emotional support for their families and caregivers. 

The program covers all ages and is stated to be different from 

hospice in the following five ways: the program is applied earlier 

in the disease process than hospice; it does not require a sixmonth 

prognosis; it can be utilized with traditional curative 

care; it can be accessed while the patient is undergoing 

rehabilitation at a skilled nursing facility; it provides physician 

and nurse practitioner consultations whereas hospice includes 

an array of services such as 24-hour support from the 

interdisciplinary hospice care team, as well as durable 

equipment. 

• Touch of All Seasons – a comprehensive program designed for 

patients with advanced dementia and other neurological 

illnesses, stated to have been developed by Joyce Simard, MSW, 

an internationally recognized dementia expert 11 . Goals of this 

program are, in summary, to overall reduce pain and suffering, 

maintain dignity and support the family. Benefits to this 

program are, in summary, to overall have a person centered 

care approach for this population, enhance comfort, create 

calm, teach loved ones how to interact and add a layer of 

professional caregivers to the existing team. 

• Open Access – Seasons states experience with hospice care 

where the patient suffers complications or multiple system 

involvement in addition to the terminal diagnosis and provides 

60


services such as ventilator-at-home care, radiation therapy and 

chemotherapy. These three services are specifically 

conditioned. The applicant notes some services that may apply 

in a multiple system involvement patient are as follows: IV 

antibiotics, TPN, IV hydration, cardiac drips, chest tubes, tube 

feedings, hemo/peritoneal dialysis for co-occurring diagnosis, 

palliative radiation, oral chemotherapy, biological response 

modifiers (such as Procrit, Neupogen, Epogen), patients needing 

additional time to complete the discharge planning from the 

acute care setting, and patients who must finish a course of 

treatment. Seasons identifies the following seven benefits to the 

Open Access Program: 

• increases the time for patients and families to engage in 

advance care planning and process issues related to the 

advanced illness while utilizing hospice care services; 

• allows patients to receive hospice care services earlier and 

provides them with more assistance in care planning; 

• supports collaborative effort between the hospice team and 

the hospital or other discharge planning team during 

difficult communications with patients and their families; 

• begins hospice services while the patients are transitioning 

from curative care to palliative care; 

• helps patients and families understand when care is futile 

and allows them to request discontinuation of measures on 

their own schedule; 

• demonstrates significant length of stay reduction in the 

acute care setting and; 

• incorporates the referring physician's recommendations into 

coordinated plan of care with the patient and family. 

• Education – is stated to be of the highest caliber available, with 

external/community education so that required CEUs can be 

acquired to maintain licensure and certifications. Seasons 

states it works with Boards of Nursing to become a provider of 

continuing education. 

61


• Kangaroo Kids – a summer support camp for bereaved children 

to include a weekend trip with parent/guardian to one of 

Florida‟s theme parks. The applicant indicates this is a 

specialized program and is conditioned 12 . According to the 

applicant, Kangaroo Kids is a program with a total medical, 

spiritual, emotional, physical, and social approach that focuses 

on caring for the patient's entire family: parents, siblings, and 

grandparents. Kangaroo Kids is described as a unique pediatric 

program dedicated to offering all-encompassing care to children 

who are suffering life-threatening illnesses and/or death. It is 

based on the belief that these children can thrive best when 

their families are encouraged to care for their child at home, 

with resources and support from hospice. Seasons states that 

goals of the program are as follows: to enhance the quality of life 

for children and their families, to relieve suffering; to control 

symptoms, to enable children to stay at home with their 

families, to provide caring expertise and support, letting families 

know they are not alone and have a shoulder to lean on; to 

encourage children to retain their independence and a sense of 

being respected for who they are and to help family members 

move through their emotions and resolve spiritual questions. 

According to Seasons, the types of medical conditions seen in 

the program include the following: neurodegenerative disorders, 

severe metabolic or genetic diseases, end-stage cancers, AIDS, 

severe neuromuscular diseases, inoperable cardiac defects, 

severe congenital anomalies, and severe multi-system disorders. 

• Volunteer Vigil Program – these are direct care volunteers who 

have completed all core volunteer requirements, six months 

active patient care, express Vigil interest and are available to be 

called to service within their defined area of service at a 

minimum of two-hour shifts on a regular basis. 

• Call Center – a Seasons operated call center for afterhours 

triage of calls with Seasons employees who are specially trained 

in hospice and palliative care and have access to all patients' up 

to date patient information. Stated to be a fully electronically 

integrated system with electronic medical records and other 

communication devices used by employees, it is tied-in with 

12 CON Application #10063, page #2-17. The Agency notes that while the Kangaroo Kids and Kangaroo 

Camp programs are conditioned, the applicant does not condition specifically that the program will 

include a weekend trip to one of Florida‟s theme parks. 

62


“HomeWorks” (a stated telehealth and patient data collection 

and analysis system). Seasons indicates it will be fully 

integrated into the national system, allowing support and 

tracking, with on-line assistance to staff, who in-turn can 

respond more timely, 24 hours a day, seven days a week. This 

is conditioned by the applicant. 

United Hospice of Florida, Inc. (CON #10064) states that all 

patients eligible for hospice care will be accepted that are not 

covered by private insurance, Medicaid or Medicare. As evidence of 

United‟s commitment to serve all those that seek care, the 

applicant indicates that in its fiscal year 2009, it provided more 

than $223,000 in unfunded care. The applicant restates its 

conditions as non-core services. They are repeated here. 

1. UHS Home and Community Based Services Provider: Upon 

CON approval, United Hospice's ultimate parent, UHS, will 

develop, in conjunction with United Hospice, UHS' family of 

services and companies in Subdistrict 4A and will enhance 

the hospice services available to area residents by making 

such services available not only to United's hospice patients, 

but also to any other existing hospice provider who wishes to 

contract for such services. The United Hospice family of 

services and companies include United Home Care, United 

Medical, United Pharmacy Services and United Clinical 

Services. This will be measured by a signed declaratory 

statement submitted by United Hospice to the Agency. 

2. African American Outreach: Reflective of its commitment to 

enhancing access to the end-of-life care of African American 

residents in Subdistrict 4A, the applicant has conditioned 

approval of its application on the provision it will implement 

and maintain an African American Outreach Program. 

• A staff member will be responsible for the outreach 

initiatives. This individual's objective will be to coordinate 

staff activities, plan events and serve as a key contact 

within community leaders. 

• United Hospice will form a planning and outreach team 

consisting of staff, volunteers and community members. 

This team will provide support for the staff person 

assigned primary responsibility for outreach effort. 

• United Hospice will host listening sessions with African 

American leaders, African American clergy and other 

members of the African American community to develop 

63


an understanding of attitudes and beliefs regarding endof-life 

care. Some of these organizations will include but 

are not limited to: 

• Local NAACP branches 

• Jacksonville Urban League 

• Black Chamber of Commerce 

• Jacksonville city Mayor's office 

• State Representative Mia Jones 

• State Senator Tony Hill Sr. 

• State Representative Audrey Gibson 

• Other City and County Leaders 

• Churches and other religious affiliated groups 

• Based on listening sessions, United Hospice will develop a 

message, presentation and marketing materials that 

address needs and issues expressed by focus group 

respondents and the community. 

• United Hospice will continually assess existing tools and 

obtain or develop new resources as needed to provide 

culturally meaningful and appropriate educational 

opportunities for the African American community. 

• The applicant will provide ongoing comprehensive 

training for staff and volunteers who are actively involved 

in the outreach program. These individuals will plan 

quarterly town hall meetings with members of the 

community to engage, educate and energize individuals to 

begin end-of-life conversations in their organizations, 

congregations and so forth. 

• United Hospice will develop and maintain a calendar of 

events that address, support and celebrate African 

American issues, heritage and healthcare concerns. Staff 

members will attend various calendar events with the goal 

of making United Hospice of Florida the name and face 

known throughout the community. 

• The applicant will develop a census tracking tool to 

routinely track referrals generated by the outreach 

program to measure its ongoing success. 

• The applicant will report its admissions annually by race, 

to measure success and increase in percentage of African 

American admissions. 



64


3. Homeless Outreach: If awarded a certificate of need for the 

proposed project, United Hospice will partner with the ESHC to 

provide hospice services to Subdistrict 4A homeless individuals in 

either a residential or homeless shelter setting coordinated by 

ESHC. Specifically, United Hospice will accept the following 

conditions on its CON: 

• Continue active membership in the ESHC through attendance 

at monthly meetings and collaborating with coalition members 

in providing services to the homeless population. 

• Provide hospice services to homeless population in shelters and 

assist with facility placement as appropriate. Shelters may 

include but are not limited to City Rescue Mission, Hubbard 

House, the Salvation Army, the Sulzbacher Center and Trinity 

Rescue Mission. 

• United Hospice will provide health screenings at by a registered 

nurse once a month at one of the local not-for-profit social 

service organizations to be determined in collaboration with the 

ESHC. 

4. Rural Areas Outreach: United Hospice has conditioned this 

application on the provision it will open a main office in 

Jacksonville plus two satellite offices in rural areas of Subdistrict 

4A as follows: 

• A Baker County office will open immediately upon licensure to 

serve the terminally-ill needs of Baker County residents. 

• A Nassau County office will open by the end of United Hospice's 

second year of operation. 

• Both the Baker and Nassau County offices will be centrally 

located to the population and will have a dedicated 

interdisciplinary team. 

• United Hospice will become a member of and will partner with 

the St. Johns Rural Health Network to improve the health of the 

communities in which United Hospice serves. 

5. Patients in Need of Continuous Care: United Hospice has 

conditioned this application on the provision it will provide, at a 

minimum, 2.5 percent of its patient days by the end of year two to 

continuous care which exceeds the state average, to the extent in 

which there is patient demand as determined by the 

interdisciplinary team. This condition will be measured via a 

signed declaratory statement by United Hospice which may be 

supported via review of patient day reports by type and month 

65


produced by the applicant. United Hospice will monitor and 

annually report to the Agency, overall Subdistrict 4A continuous 

care percentage of patient days to determine success of its 

continuous care initiative. 

6. CHAP Accreditation: United Hospice has conditioned approval of 

this application on the provision it will seek and obtain CHAP 

accreditation upon certification. This will be measured by 

submitting United Hospice's accreditation certificate to the Agency 

upon receipt. 

7. Membership Organizations: Upon licensure, United Hospice will 

become a member of the following community organizations: 

• Florida Hospice and Palliative Care; 

• Jacksonville Regional Chamber of Commerce; 

• St. Johns County Chamber of Commerce; 

• Greater Nassau County Chamber of Commerce; 

• Clay County Chamber of Commerce; and 

• Baker County Chamber of Commerce. 

8. United Hospice Foundation: United Hospice Foundation will make 

available to Florida residents, its annual scholarship program 

targeted at those who are studying nursing, pharmacy or therapy 

with an interest in end-of-life care. The scholarship is available 

each year to four students in the amount of $2,000 for the school 

year. 

9. Staffing Ratios and Qualification: United Hospice will meet or 

exceed all NHPCO Guidelines for qualifications and staffing ratios 

for patient care staff. 

10. Pain Reduction: United Hospice will implement rapid pain 

management protocols to ensure that 75 percent of patients who 

report severe pain on a 0-10 scale will report a reduction to five or 

less by the end of the second day of care on the hospice program. 

This condition substantially exceeds the requirements of section 

400.60501, Florida Statutes. For patients that do not meet this 

pain reduction goal, such patient's plan of care will be evaluated 

within 48 hours by the medical director and a Pharm D. 

consultant to ensure that appropriate pain reduction measures are 

immediately implemented. 

66


VITAS Healthcare Corporation of Florida (CON #10065) states that all 

patients eligible for hospice care will be accepted that are not covered by 

private insurance, Medicaid or Medicare. As evidence of VITAS‟ 

commitment to serve all those that seek care, the applicant indicates 

that in fiscal year 2008, it provided in excess of $1.9 million in charity 

care. The applicant restates its conditions as non-core services. They 

are repeated here. 

1. The first population subgroup is defined as hospice patients in 

need of continuous care: VITAS will provide at least three percent 

of its total patient days to continuous care by the end of year two. 

2. The second population subgroup is defined as hospice patients 

with diagnosis other than cancer. VITAS will guarantee that at 

least 65 percent of patients admitted have non-cancer diagnoses. 

3. Special Programs: VITAS has conditioned the application on the 







These measures will be recorded in VITAS's proprietary 









quality care. 

• Death Attendance: VITAS will attend at least 90 percent of all 

deaths to ensure patients do not die alone. This will be 

measured via a signed declaratory statement by VITAS which 

may be supported via review of patient medical records. 

• Patient Family Satisfaction: VITAS will achieve an overall 

patient satisfaction score of 90 percent or above on patient's 

family evaluation of care while under the care of VITAS. This is 

determined by a mail-in survey sent by VITAS to the patient's 

family and measured by recording all scores. 

67


• Discipline Specific Satisfaction: VITAS will achieve an overall 

registered nurse satisfaction score of 90 percent or above on 

patient's family satisfaction with the VITAS nurse while under 

the care of VITAS. This is determined by a mail-in survey sent 

by VITAS to the patient's family and measured by recording all 

scores. 










4. Other Conditions: VITAS has conditioned its application on the 

provision it will meet or exceed the following operational and 

programmatic indicators: 














• VITAS will admit all eligible patients without regard to their 

ability to pay. 










68





workers. 


















at Jacksonville to fund an Endowed Teaching Chair, 

Scholarships, and the Northeast Florida Initiative for Nursing 










identifying not-for-profit organizations in need of funding. The 

charitable contribution condition will be measured via a signed 

declaratory statement by VITAS and evidence of funds 

transferred. The correspondence between VITAS and United 

Way of Northeast Florida describing the donation process is 

found behind TAB 11. 

69







which is predominantly the underserved African-American 






b. Chapter 59C-1.0355, Florida Administrative Code contains the 

following general provisions and review criteria to be considered in 

reviewing hospice programs. 

(1) Required Program Description (Rule 59C-1.0355(6), Florida 

Administrative Code): An applicant for a new hospice program 

shall provide a detailed program description in its certificate 

of need application, including: 

(a) Proposed staffing, including use of volunteers. 

Compassionate Care Hospice of Florida, Inc. (CON 

#10061) states it will provide staff to equal or exceed State of 

Florida and Medicare guidelines. Compassionate Care‟s 

Schedule 6A indicates 34.9 FTEs in year one (ending June 

30, 2011) and 52.1 FTEs in year two (ending June 30, 2012). 

Compassionate Care states it will utilize an interdisciplinary 

team model. The applicant states that by including a wide 

range of personnel skills and experience and input from the 

family, Compassionate Care believes that the patient and the 

family are the primary unit of care. Other members of the 

care team include: patient‟s primary hospice physician, 

hospice medical director, registered nurse, social worker, 

certified home health aides/nursing assistants, therapists (to 

be utilized on a contractual basis), dieticians, bereavement 

counselors, chaplains, and trained volunteers. Additional 

staff will be added as needed. This applicant includes an inhouse 

physician as do co-batched applicants Odyssey 

HealthCare of Collier County, Inc. and VITAS Healthcare 

Corporation of Florida. 

70


Odyssey HealthCare of Collier County, Inc. d/b/a 

Odyssey HealthCare of Central Florida (CON #10062) 

states it will provide each patient and family with a “Circle of 

Care”; an interdisciplinary team of its employees and the 

patient‟s physician dedicated to providing a high-level of care 

and assistance to patients and their families as designed and 

in use by the applicant. The interdisciplinary team is stated 

to be specialized in end-of-life care and in pain and symptom 

management. The manager of the interdisciplinary team is 

the nurse who assesses the needs of the patient and family. 

The applicant states that in addition to the nurse case 

manager, the patient‟s attending physician and the medical 

director, the interdisciplinary team also includes the 

following: a home health care aide (for direct patient care); a 

chaplain (addressing concerns of a spiritual nature); a social 

worker (addressing psycho-social needs of patients and 

family members); trained volunteers (for companionship and 

supportive non-medical services); a bereavement coordinator 

(to manage support groups, newsletters and referrals) and an 

on-call nursing team. The applicant‟s Schedule 6A indicates 

a total of 17.7 FTE‟s dedicated to serving the program in year 

one (ending December 31, 2011) and 25.0 FTE‟s in year two 

(ending December 31, 2012). This applicant includes an inhouse 

physician, as do co-batched applicants 

Compassionate Care Hospice and VITAS Healthcare 

Corporation of Florida. 


notes, from Schedule 6A, a total of 41.0 FTEs in year one 

(ending December 31, 2011) and 62.84 FTEs in year two 

(ending December 31, 2012). Categories of staff include the 

following: administration; medical director (by contract 

stated in schedule assumptions); nursing; dietary and social 

services. The applicant primarily identifies direct patient 

care volunteers and indirect patient care volunteers. As 

implied, the direct patient care volunteers provide comfort, 

support and/or practical assistance to adults and children. 

The Volunteer Vigil Program is within this category. Indirect 

patient care volunteers provide administrative assistance or 

special projects that enhance the work of in-house staff, 

supporting patients, families and the efforts of teams in the 

field. 

71


United Hospice of Florida, Inc. (CON #10064) notes, from 

Schedule 6A, a total of 16.97 FTEs in year one (ending date 

not stated) and 44.35 FTEs in year two (ending date not 

stated). Categories of staff include the following: 

administration; physician (by contract), nursing, ancillary 

(by contract), dietary, and social services. Schedule 6A 

agrees with the applicant‟s staff table for year one average 

number of FTEs (16.97 FTEs, for year one) but for year two, 

the table states an average number of FTEs of 42.76 

compared to the Schedule 6A total of 44.35 FTEs. 

VITAS Healthcare Corporation of Florida (CON #10065) 

notes, from Schedule 6A, a total of 17.49 FTEs in year one 

(ending June 2011) and 39.08 FTEs in year two (ending 

June 2012). Categories of staff include the following: 

administration, physician, nursing, ancillary (by contract 

and including dietary staff) and social services. This 

applicant includes an in-house physician, as do co-batched 

applicants Compassionate Care Hospice and Odyssey Health 

Care of Collier County. 

(b) Expected sources of patient referrals. 


#10061) states that patient referrals are expected to come 

from numerous sources, including physicians, hospital 

social workers and case managers, long-term care facilities, 

other community-based agencies, and family members and 

others. The applicant states it has started to develop 

relationships with area health care providers and social 

service agencies in Hospice Service Area 4A and will continue 

to do so once approved. The applicant intends to educate 

the existing providers about the types of services it can 

provide to their patients. The applicant has conditioned for 

a full-time staff member, located in the City of Jacksonville 

to serve all five counties, to serve exclusively as an outreach 

coordinator to the non-health care community. 



states it will actively seek referrals through physicians; longterm 

care facilities (including nursing homes and assisted 

living facilities/adult care centers), hospitals, patients/ 

patient families, and managed care and insurance 

companies. The applicant notes interest in ALF providers, 

72


included support letters from local ALFs in the area and 

provides materials on such relationships (CON Application 

#10062, Appendix I-Odyssey and Assisted Living). Though 

the applicant states it is in the process of obtaining 

memoranda of understanding for general inpatient contracts 

for local Hospice Service Area 4A providers, Odyssey is the 

sole co-batched applicant that lacked a commitment letter to 

enter into a written inpatient bed arrangement for hospice 

services, should the project be approved. 


comments that hospice is often called upon as an 

“intervention”, as if impending death was somehow not 

foreseen and that many frail elderly of advanced age are, in 

fact, terminal, as no more curative options are available. 

Considering this, Seasons states interest in more outreach 

and education toward more timely hospice care. In this 

context, the applicant expects referrals from nursing homes, 

hospitals, assisted living facilities, comprehensive medical 

rehabilitation facilities, long-term care hospitals, physicians, 

families, individuals, advocates for the homeless, advocates 

of AIDS and HIV+ groups, and military related organizations 

within the area. While the applicant states interest in 

outreach to these groups, letters of support do not bear out 

due diligence in reaching out to these groups local to 

Hospice Service Area 4A, with the exception of one letter of 

support from a Clay County long-term care hospital – 

Kindred Hospital North Florida. However, the applicant 

conditions to contribute (within six months of final CON 

approval) $50,000 of outreach, promotion and expansion of 

hospice services in Clay County, release to the local area the 

Seasons Hospice & Palliative Care Newsletter, PharmSmart 

and a local advisory board to address local hospice needs in 

Hospice Service Area 4A. 

United Hospice of Florida, Inc. (CON #10064) states that 

referrals are expected from: physicians; hospitals; nursing 

homes; other health care providers; family members and 

patients. The applicant has 17 letters of support from a 

combination of local hospitals, SNFs, ALFs, organizations for 

the homeless and ministerial/social service organizations. 

The applicant conditions, particularly, toward outreach to 

African Americans, the homeless and rural areas in the 

hospice service area, with a staff member dedicated to this 

purpose. 

73



reports 23 successful hospice start-ups in the past decade 

and states it has the ability to enter a community with 

established hospices and develop referral sources. The 

applicant expects referrals from: physicians, hospitals, 

clergy, social service agencies, disease advocacy groups, 

nursing homes and other health care providers, family 

members and patients. The applicant has letters of support 

from organizations for the aged; minority affiliates, health 

care centers (including a local FQHC), ALFs, nursing homes, 

hospitals, social service agencies, state, county and city 

elected officials. This applicant conditions that a designated 

hospice representative will provide community outreach, 

promote hospice awareness and enhance access to African 

Americans in the service area and make charitable 

contributions of $300,000 to the Florida State College/ 

Northeast Florida Initiative for Nursing Workforce Diversity 

Program, up to $500,000 to the United Way of Northeast 

Florida and $50,000 to the Jacksonville Urban League. The 

applicant has letters of support from these organizations. 

(c) Projected number of admissions, by payer type, 

including Medicare, Medicaid, private insurance, selfpay, 

and indigent care patients for the first two years of 

operation. 

The table below is provided, to illustrate projected 

admissions for years one and two for each of the co-batched 

applicants. 

Total Projected Admissions By Applicant 

for Years One and Two 

CON # Applicant Year One Year Two Both Years 

10061 Compassionate 275 415 690 

10062 Odyssey 155 271 426 

10063 Seasons 402 615 1,017 

10064 United Hospice 222 528 750 

10065 VITAS Healthcare 162 297 459 

Source: CON Application #s 10061-10065. 

As indicated in the table above, Seasons (CON #10063) 

anticipates serving a total of 1,017 patients in the first two 

combined years, the most of any co-batched applicant, while 

Odyssey (CON #10062) anticipates serving a total of 426 

patients in the first two combined years, the fewest of any 

co-batched applicant. As described in the tables for each co- 

74


batched applicant below, Odyssey (CON #10062) anticipates 

serving the highest percentage of Medicare patients in the 

first two years of operation and Compassionate Care (CON 

#10061) anticipates serving the lowest percentage of 

Medicare patients in the same period. Compassionate Care 

(CON #10061) projects to serve 32 self-pay/uncompensated 

patients, followed by Seasons (CON #10063) with 25 

charity/uncompensated patients, Odyssey (CON #10062) 

with 17 commercial/charity/other patients, United (CON 

#10064) with seven indigent patients and VITAS (CON 

#10065) with five indigent patients 13 . It is noted that 

hospice programs are required by federal and state law to 

provide services to everyone requesting them, regardless of 

ability to pay. 


#10061) provides estimates as shown below regarding 

admissions by payer type in the first two years of operation. 

Expected Admissions by Payer Type 

For Compassionate Care Hospice of Florida, Inc. - CON #10061 


Payer Type Year One Year Two 

Medicare 209 324 

Medicaid 14 21 

Commercial/Other 28 62 

Self-Pay/Uncompensated 24 8 

Total 275 415 

Source: CON Application #10061, page #61. 

As shown in the table above, the applicant intends to serve 

275 and 415 patients in its first and second year of 

operation, respectively. Medicare will comprise 76.0 percent 

of admissions during the first year and 78.07 percent during 

the second year of operations. Self-pay/uncompensated care 

is expected to comprise 8.73 percent in year one and 1.93 

percent in year two. 



provides estimates as shown below regarding admissions by 

payer type in the first two years of operation. 

13 Several applicants combine payer categories and it is not sure as to the actual number of 

indigent/charity care patients they project to serve. A self-pay patient could be paying for care. It 

appears that Seasons with 25 patients listed as charity/uncompensated may propose to serve more 

charity care patients than Compassionate Care which includes self-pay. Odyssey includes commercial 

and „other‟ in its charity patient numbers. 

75


Projected Odyssey HealthCare of Collier County, Inc. 

d/b/a Odyssey HealthCare of Central Florida 

Admissions by Payer CON #10062 

Years One and Two of Operation 




Medicaid 5 8 

Commercial/Charity/Other 6 11 

Total 155 271 




operation, respectively. Medicare will comprise 92.90 

percent of admissions during the first year and 92.99 

percent during the second year of operations. Commercial/ 

charity/other is expected to comprise 3.87 percent in year 

one and 4.06 percent in year two. 





For Seasons Palliative Care of Florida, Inc. #10063 





3 rd Party Insurance 20 31 

Self-Pay 2 3 

Charity/Uncompensated 10 15 

Other 0 0 

Total 402 615 

Source: CON Application #10063, Table 1-10 on page #1-36. 





percent of admissions during the second year of operations. 

Self-pay care is expected to be 0.50 percent in year one and 

0.49 percent in year two, while charity/uncompensated care 

is expected to be 2.49 percent in year one and 2.44 percent 

in year two. 

76


United Hospice of Florida, Inc. (CON #10064) provides 

estimates as shown below regarding admissions by payer 

type in the first two years of operation. 


For United Hospice of Florida, Inc. - CON #10064 





Indigent 2 5 

Insurance/Managed Care/Other 4 9 

Total 222 528 







Indigent care is expected to be 0.90 percent in year one and 

0.95 percent in year two. 





For VITAS Healthcare Corporation of Florida - CON #10065 




Medicaid 8 15 

Indigent 2 3 

Private Insurance/Self-Pay/Other 3 6 

Total 162 297 







Indigent care is expected to be 1.23 percent in year one and 

1.01 percent in year two, while private/self-pay/other care is 

expected to be 1.85 percent in year one and 2.02 percent in 

year two. 

77


(d) Projected number of admissions, by type of terminal 

illness, for the first two years of operation. 


#10061) provides the following table illustrating the 

projected number of admissions by type of terminal illness 

for the first two years of operation. 

Projected number of Admissions by Diagnosis 

For Compassionate Care Hospice of 

Florida, Inc./CON #10061 



Disease Year One Year Two 

Cancer 100 151 

Non-cancer 175 264 

Total 275 415 




provides the following table illustrating the projected number 

of admissions by type of terminal illness for the first two 

years of operation. 

Projected Admissions by Diagnosis for Odyssey 

HealthCare of Collier County, Inc. 

d/b/a Odyssey HealthCare of Central Florida/CON #10062 




Cancer 48 84 

Alzheimer‟s/Dementia 22 38 

Congestive Heart Failure 26 46 

COPD 14 24 

Debility 19 33 

Renal 5 8 

Liver/Other 21 38 

Total 155 271 


The applicant projects to serve 155 patients in year one and 

271 patients in year two. 





78


Projected Admissions by Diagnosis for Seasons Palliative Care 

of Florida, Inc./CON #10063 




Cancer 146 224 

Non- Cancer 256 392 

Total 402 616 

Source: CON Application #10063, page #1-38. 

The applicant‟s table 1-13 indicates that it projects to serve 

402 patients in year one and 615 patients in year two. 

However, year two computes to 616 admissions. 

United Hospice of Florida, Inc. (CON #10064) provides the 

following table illustrating the projected number of 

admissions by type of terminal illness for the first two years 

of operation. 

Projected Admissions by Diagnosis for United Hospice of 

Florida, Inc. - CON #10064 




Cancer 44 106 

HIV/AIDS 9 15 

Respiratory 20 46 

Cardiac 68 161 

Renal Failure 12 22 

Alzheimer/Cerebral Degeneration 25 57 

Cerebrovascular/Stroke 19 46 

Other 23 75 

Total 222 528 








79


Projected Admissions by Diagnosis for VITAS Healthcare 

Corporation of Florida - CON #10065 




Cancer 52 95 

HIV/AIDS 2 3 

Respiratory 13 23 

Cardiac 22 41 

Renal Failure 2 4 

Alzheimer/Cerebral Degeneration 34 62 

Cerebrovascular/Stroke 10 20 

Other 27 49 

Total 162 297 




(e) Projected number of admissions, by two age groups, 

under 65 and 65 or older, for the first two years of 

operation. 


#10061) projects 275 admissions in its first year of 

operations and 415 in the second year. The projected 

number of admissions by age groups under 65 and 65 or 

older appears in the following table. 

Projected Number of Admissions by Age Group 

for Compassionate Care Hospice of Florida/CON #10061 


Service Area 4A 

Under 65 65 or Older Total 

Year One 61 214 275 

Year Two 92 323 415 




projects 155 admissions in its first year of operations and 

271 in the second year. The projected number of admissions 

by age groups under 65 and 65 or older appears in the 

following table. 

80


Projected Number of Admissions by Age Group for Odyssey 

HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of 

Central Florida/CON #10062 




Year One 16 139 155 

Year Two 27 244 271 







Projected Number of Admissions by Age Group for Seasons 

Palliative Care of Florida, Inc./CON #10063 




Year One 89 313 402 

Year Two 136 480 615 

Source: CON Application #10063, page #1-38. 

The applicant‟s total year two admissions count is stated to 

be 615; however, year two adds up to 616 admissions in 

tables 1-11 and 1-13. 

United Hospice of Florida, Inc. (CON #10064) projects 222 

admissions in its first year of operations and 528 in the 

second year. The projected number of admissions by age 

groups under 65 and 65 or older appears in the following 

table. 


for United Hospice of Florida, Inc./CON #10064 




Year One 29 193 222 

Year Two 69 459 528 


81








for VITAS Healthcare Corporation of Florida/CON #10065 




Year One 23 139 162 

Year Two 42 255 297 


(f) Identification of the services that will be provided 

directly by hospice staff and volunteers and those that 

will be provided through contractual arrangements. 

The hospice care team shall directly provide the following 

core services: nursing services, social work services, pastoral 

or counseling services, dietary counseling, and bereavement 

counseling services. Physician services may be provided by 

the hospice directly or through contract. A hospice may also 

use contracted staff if necessary to supplement hospice 

employees in order to meet the needs of patients during 

periods of peak patient loads or under extraordinary 

circumstances. 

Compassionate Care Hospice of Florida, Inc. (CON 10061) 

asserts that it will provide what it lists as core services – 

physician, nursing, social work, pastoral and counseling, 

bereavement counseling, home health aide, pharmacy, 

supplies and durable medical equipment, homemaker and 

chore, and dietician/nutritionist – all directly through 

hospice staff and volunteers. Compassionate Care states 

intent to contract for the following services: physical, 

occupational and speech therapy, massage, music, inpatient 

and respite, patient transportation, and infusion. 



asserts that with the exception of physicians and a minimal 

level of contract services by physical, speech and 

occupational therapists, the majority of services will be 

provided by the hospice care team and volunteers. The 

82


applicant indicates in-house services are as follows: home 

health care aides, chaplain, social worker, volunteers, 

bereavement coordinator, and a 24/7 on-call nursing team. 


states that Seasons will provide directly the following four 

core service care categories: routine, respite, inpatient, and 

continuous. Seasons indicates staff will provide the 

following services: physician, nursing, medical social 

services, counseling (spiritual and bereavement), hospice 

aide, and homemaker, dietician and music therapy. Seasons 

also states a preference to hire a hospice medical director 

but that in seeking to fill the position, contracted 

professionals will be used. Other professionals to be 

contracted are as follows: speech, occupational, respiratory 

and physical therapy. 

United Hospice of Florida, Inc. (CON #10064) will provide 

what it lists as core services – physician, nursing, social 

work, pastoral counseling, bereavement counseling and 

dietary counseling – all directly through hospice staff and 

volunteers. The applicant also states that massage, pet and 

aroma therapy services will be provided by staff and 

volunteers. United indicates it will contract for durable 

medical equipment, pharmacy, rehabilitation, and certain 

clinical services (not otherwise specified by the applicant). 

United has letters of support from sister entities within the 

United umbrella to meet this need. 


states that it will provide what it lists as core services – 

physician, nursing, social work, pastoral counseling and 

dietary counseling – all directly through hospice staff and 

volunteers. The applicant anticipates all services will be 

provided by hospice staff with the exception of durable 

medical equipment and supplies and pharmacy services. 

From time to time, the applicant states there may be a need 

for supplemental staff employed to meet patient need, such 

as physical therapy, speech-language pathology, massage 

and occupational therapy. 

83


(g) Proposed arrangements for providing inpatient care. 

All of the co-batched applicants, except Odyssey, include 

support letters from hospital and/or skilled nursing facilities 

in Service Area 4A that are willing to contract with the 

applicant for inpatient hospice services. 


anticipates contractual arrangements with existing hospitals 

in each of the five Hospice Service Area 4A counties. 

Compassionate Care has letters of support from James 

Wood, President and CEO, Memorial Hospital-Jacksonville 

(Duval County) and from Thomas Pentz, Chief Executive 

Officer, Orange Park Medical Center (Clay County) stating 

their willingness to enter into agreements with 

Compassionate Care to provide inpatient care for 

Compassionate Care patients. 



states plans for contractual arrangements with hospitals, 

nursing homes and other appropriate settings. According to 

the applicant, it will seek similar agreement that it already 

has with these types of facilities through Odyssey 

HealthCare-Daytona (Volusia County) and Odyssey 

HealthCare-Miami/Dade (Miami-Dade County). The 

applicant further states it is in the process of obtaining such 

memoranda of understanding locally in Hospice Service Area 

4A. However, the applicant is the only co-batched applicant 

to fail to secure such commitments through letters of 

support. 


states it has experience in opening and operating hospice 

houses and inpatient units and that it expects to provide 

inpatient services with hospitals and nursing homes. The 

applicant includes a support letter agreeing to enter into a 

contractual relationship from Hoyt Ross, Chief Executive 

Officer, Kindred Hospital - North Florida (Clay County). 

United Hospice of Florida, Inc. (CON #10064) expresses 

interest in having contractual relationships with nursing 

homes and hospitals designed to meet patient needs in the 

hospice service area. Four facilities make specific reference 

84


to entering into contractual agreements in the delivery of 

inpatient services to the applicant‟s hospice patients, should 

the applicant be approved: River Point Behavioral Health 

Center and Wekiva Springs Center for Women (Duval 

County), Life Care Center of Orange Park (Clay County), and 

Quality Health of Fernandina Beach (Nassau County). 


states that it will utilize inpatient beds for hospice patients 

in existing local hospitals and nursing homes. Further, the 

applicant anticipates a need for 297 bed days in the second 

year of operation. Per VITAS, many more beds than those 

projected will be contracted for on an as-needed basis. Six 

Hospice Service Area 4A skilled nursing facilities expressed 

commitment or interest in entering into appropriate 

agreements to provide inpatient hospice beds, should this 

applicant be approved. These providers are as follows: Chris 

Adams, Executive Director; Harts Harbor Health Care 

Center; Elizabeth Sholar, NHA, Fleet Landing; Raymond 

Prudencio, NHA, CNA, Administrator and Preceptor, The 

Terrace at Fleming Island (Clay County); Glenford Wright, 

MSHRM, BSBA, Administrator, West Jacksonville Health and 

Rehabilitation Center; Jerry Tomack, MHSA, NHA, Executive 

Director, San Jose Health and Rehabilitation Center and Eric 

Weisz, Executive Director, Governor‟s Creek Health and 

Rehabilitation Center (Clay County). 

(h) Proposed number of inpatient beds that will be located in 

a freestanding inpatient facility, in hospitals, and in 

nursing homes. 

None of the applicants provided the number of inpatient 

beds they would use through the service area‟s hospitals or 

nursing homes. An existing provider, Community Hospice of 

North East Florida has three inpatient hospice facilities 

licensed for 70 beds in Jacksonville. The projects do not 

involve a freestanding inpatient hospice facility. 


estimates that 1.3 percent of total patient days will be 

required for inpatient admissions. The applicant states this 

will be achieved through contractual agreements with 

hospitals, nursing homes and freestanding hospice facilities 

in the area. 

85




does not offer a number of expected inpatient beds that will 

be needed. The applicant indicates beds will be contracted 

on an as-needed basis. 



be needed. The applicant indicates beds will be contracted 

on an as-needed basis, envisioning its own inpatient facility 

at some point in the future. 

United Hospice of Florida, Inc. (CON #10064) does not 

offer a number of expected inpatient beds that will be 

needed. The applicant indicates beds will be contracted on 

an as-needed basis. 



be needed, other than anticipating a need for 297 bed days 

in its second year of operation. The applicant indicates beds 

will be contracted on an as-needed basis. 

(i) Circumstances under which a patient would be admitted 

to an inpatient bed. 

All co-batched applicants express an interest in admitting 

patients to an inpatient bed when less intensive methods of 

care are impractical, unfeasible, ineffective or otherwise 

inappropriate, given patient desires, symptoms and caregiver 

or family dynamics. 


#10061) states that staff, in coordination with the 

interdisciplinary team, after consultation with the attending 

physician, will evaluate each patient on a case-by-case basis 

to determine admission to an inpatient facility. Some major, 

broad categories of consideration in reaching this decision 

are: pain, other symptoms (imminent death, home support 

break-down, nutritional and/or medication challenges, other 

complications, etc.) and psychosocial pathology (disturbed 

mental state, depression/anxiety in the extreme, unsafe 

home environment, disruption in family dynamics, etc.). 

86


Compassionate Care states that it will provide respite care 

when the patient‟s family/caregiver needs a short period of 

relief. This will be offered on an “as needed” basis for a 

maximum of five days per respite admission for a 

Medicare/Medicaid patient. For patients covered by other 

insurers, the duration may be approved for a longer period of 

time. 

The applicant conditions to provide at least 1.5 percent of 

total patient days to continuous care and to have continuous 

care staff at bedside within two hours of receipt of a request 

for such service and will continue it as long as needed. 



states admission to an inpatient bed is dictated by a 

patient‟s medical need and if possible, symptoms are 

addressed and care is provided in the “home” setting 

wherever that may be. However, per the applicant, inpatient 

care applies when care cannot be effectively managed in the 

home setting, when continuous care is not an option due to 

the level of caregiver support available, or patient or family 

wishes call for this care. The applicant states that patients 

are encouraged to seek the level of care with which they are 

most comfortable, including inpatient hospice care. To meet 

this need, the applicant states intent to secure inpatient 

contracts with hospitals and nursing homes in Hospice 

Service Area 4A. However, the applicant stresses a focus on 

allowing the patient to remain in their home setting at all 

times and is committed to providing continuous care, to 

which the applicant conditions but does not condition a 

given percent of patient days. 


states primarily inpatient bed admission is based on pain 

control, symptom management and for respite purposes. 

Seasons notes respite care will be provided “only on an 

occasional basis” and for no longer than five days at a time. 

This applicant does not condition to a given percentage of 

patient days to continuous care. 

United Hospice of Florida, Inc. (CON #10064) states the 

primary factors in the inpatient admission decision are the 

patient‟s physical condition, which fluctuates with time, and 

the home care situation. Pain and symptom control are 

87


stated to be major considerations. The patient, family, 

physician and the interdisciplinary team are stated to be 

part of the evaluation process in making an inpatient 

placement decision. The applicant conditions to 2.5 percent 

of total patient days by the end of year two are dedicated to 

continuous care services. 


states the primary factors in the inpatient admission 

decision are the patient‟s physical condition and the home 

care situation. Respite care may be provided (up to five 

days). VITAS conditions to the highest percentage of patient 

days to continuous care of at least 3.0 percent. 

(j) Provisions for serving persons without primary 

caregivers at home. 

All co-batched applicants state that they have mechanisms 

and procedures in place to address patient needs for serving 

persons without primary caregivers at home. 


indicates that it does not require that a patient have a 

caregiver in the home to be part of their program. The 

applicant states it has provided care to individuals in 

boarding homes, homeless shelters, psychiatric centers, and 

correctional facilities and that it serves all patients including 

those who live alone, transients, and those who have AIDS, 

or are homeless. The applicant states that if a homeless 

patient desiring Compassionate Care Hospice care is 

discharged from a hospital and has nowhere to go, 

Compassionate Care will place them in an inpatient unit and 

apply for Medicaid. Once the patient qualifies and receives 

Medicaid, they will be placed into a long-term care 

environment in which hospice care can still be provided as 

long as the patient requires such care. 



states that it accepts all patients who meet admission 

criteria, including patients who do not have a primary care 

giver at home, the homeless and patients with AIDS. The 

applicant explains that an Odyssey nurse will coordinate 

appropriate action and placement with the rest of the 

interdisciplinary team and hospice physician or attending 

88


physician. Odyssey describes numerous mechanisms to 

address admissions and placement (CON Application 

#10062, page #83 and Appendix F - Policies & Procedures 

Matrix). 


expects that some persons will not have a designated person 

who can function as the primary caregiver. The team leader 

will identify and direct safe and effective provision of hospice 

care in situations where the terminally ill patient requires 

assistance with self-care and skilled services. The applicant 

states that care will be provided in a location in accordance 

with the patient‟s wishes. The applicant indicates that a 

comprehensive patient and family assessment will be 

completed to determine the degree of care needed. The 

applicant provides its Policy on Persons without Primary 

Caregivers in Exhibit 4-3 (CON Application #10063, 

page #4-50). 

United Hospice of Florida, Inc. (CON #10064) commits to 

serving those who do not have a primary caregiver, the 

homeless and those with AIDS. United, more than any other 

co-batched applicant provides substantial letters of support 

from organizations that serve the homeless in the area and 

conditions to serve selected homeless shelter facilities and 

organizations, many of whom would not have a primary 

caregiver. The applicant states it will request a caregiver 

upon admission and if a caregiver is not identified, United 

Hospice states it will develop, as part of the plan of care, a 

means by which daily care and safety needs of the patient 

will be met. It is further stated the applicant will seek to 

assist in developing a caregiver network, when needed. If a 

caregiver arrangement cannot be established in the least 

restrictive environment practical, the applicant reports it 

may recommend placement in an ALF or SNF, in which 

residential care would be available. 


states that if a patient lives alone and a caregiver is not 

nearby and able to care for the patient, VITAS will assist the 

patient in developing an applicable network. VITAS will also 

89


recommend qualified adult sitter services, if applicable and 

provided a financial hardship is not created. According to 

the applicant, nursing home and ALF options will be 

considered for patients that are not able to care for 

themselves and lack a caregiver support group. 

(k) Arrangements for the provision of bereavement services. 

Here is a brief summary of each applicant‟s comments on 

bereavement services. According to the applicant‟s policy, 

Compassionate Care’s (CON #10061) on-going 

bereavement services are concluded at the end of 13 months, 

though the applicant states these services are available up to 

15 months after a patient‟s death. Compassionate Care also 

references a pediatric bereavement program called 

Compassionate Courage. Odyssey (CON #10062) indicates 

bereavement services will be available 12-13 months, post 

death, conditions for 0.5 FTEs for a dedicated bereavement 

coordinator and conditions for a children‟s bereavement 

camp in Florida by the end of the first year in operation. 

Seasons (CON #10063) conditions for Kangaroo Kids and 

Kangaroo Camp and provides for bereavement services for 

not less than 13 months. United Hospice (CON #10064) 

provides for bereavement services for up to 13 months after 

the patient‟s death or longer if needed but does not condition 

for any given bereavement services, though does state that 

Camp Cocoon will be available to children in the service 

area. VITAS (CON #10065) conditions that while 

bereavement services are generally provided for one year (12 

months) after the death of the patient, services will be 



states that it will provide bereavement services to the 

surviving family members for up to 15 months after the 

patient‟s death. However, according to the applicant‟s 

policy 14 , on-going bereavement is concluded at the end of 13 

months if the bereaved is no longer in need of bereavement 

services. Bereavement services will begin with an initial 

bereavement risk assessment to be completed by the social 

worker, bereavement coordinator or designee within three 

days of admission or at the earliest convenience of the 

patient/family/caregiver. The applicant states that the 

14 CON Application #10061, Appendix Q-Bereavement Services/Policy #2003.7:Procedure #11. 

90


bereavement coordinator may also provide supportive 

counseling prior to the death of the patient but within two 

weeks after the death of the patient, a sympathy card will be 

sent to the bereaved. 

Bereavement counselors work with patients and families to 

assist with coping, grief work, and bereavement care and 

teach grieving families how to find healthy paths to healing. 

Trained volunteer counselors may be assigned to make 

regular contacts. Compassionate Care further states that a 

pediatric-oriented program called Compassionate Courage 

will be made available, what the applicant calls a Children‟s 

Bereavement Network. In summary, this program is 

designed to provide support to children dealing with “a 

significant loss”, does not seek to achieve resolution of a 

child‟s grief but provides support and teaches coping skills. 

Compassionate Care offers no bereavement conditions in its 

Schedule C. 



states bereavement services begin with an initial assessment 

by an Odyssey nurse (an RN) during patient admission and 

continue after the patent‟s death. The bereavement 

coordinator is a part of the psychosocial/interdisciplinary 

team. The applicant states it offers the following 

bereavement activities and services: condolence 

correspondence, written materials, articles, and resources, 

one-on-one counseling, bereavement letters, grief support 

groups, memorial services, and a holiday bereavement 

program. Odyssey states it has been contacted by local 

hospitals for assistance with the families of dying patients 

not on hospice service and though not reimbursable for 

Odyssey, the staff has provided bereavement services to 

provide support to the non-hospice as well as hospital staff. 

According to the applicant‟s policy 15 , a bereavement 

coordinator will contact the bereaved within 15 days 

following patient death and bereavement services will be 

available for 12-13 months, post death. 

15 CON Application #10062, Appendix F-Policies & Procedures Matrix: Policy #15.7-Bereavement 

Services. 

91

16 http://www.cetacanyon.org/contact.php 


Through the Odyssey VistaCare Foundation (the 

Foundation), the applicant states it offers “SKY Camp” – a 

free weekend camp for children ages seven to 17 grieving the 

death of a loved one. SKY Camp opened in 1998 at Ceta 

Canyon Camp & Retreat Center 16 (a ministry of the 

Northwest Texas Conference of the United Methodist 

Church, located in Happy, Texas). Children attend the camp 

as guests of the Foundation. This is at no charge to their 

families. Stated activities at the camp are: swimming, 

basketball, volleyball, ping-pong, and the challenge course - 

physical challenges designed for the various age groups 

(such as climbing, balancing and teamwork). In essence, 

this program is designed to reduce feelings of isolation and 

fear, and then to help the survivors move on. SKY Camp 

also includes family support groups and individual grief 

counseling. The applicant conditions for 0.5 FTEs the first 

year of operation for development efforts regarding 

community bereavement programs in the area which will 

extend beyond the families of patients admitted to Odyssey 

HealthCare. The applicant further conditions that the 

Odyssey VistaCare Hospice Foundation will facilitate the 

provision of a children‟s bereavement camp in Florida by the 

end of the first year of operation, similar to Odyssey‟s SKY 

Camp, Camp Healing Tree and Camp Odyssey. 


considers bereavement services as a core service that must 

be provided to complete the applicant‟s “Circle of Care”. The 

duration of bereavement care is stated to vary, depending on 

the need. Seasons indicates bereavement services will be 

offered following the death of a hospice patient for not less 

than 13 months, to the extent desired by the bereaved and 

such services will not be terminated except by the request of 

the bereaved or upon referral of the family to outside 

agencies when mental health/family dynamics issues 

interfere with appropriate grieving. Assessments, by the 

interdisciplinary team, are part of this process. At least one 

memorial service per year for bereaved family members and 

significant others will be hosted by Seasons. Kangaroo Kids 

and Kangaroo Camp are conditioned by the applicant, 

designed for terminally-ill children. 

92

17 CON Application #10065, Tab 22. 


United Hospice of Florida, Inc. (CON #10064) states 

bereavement counseling will be provided by a staff social 

worker or chaplain to family members and significant others. 

This service will be offered for a minimum of up to 13 

months after the patient‟s death or longer if needed. The 

applicant is prepared to address differing interventions. At 

the time of the patient‟s admission, an assessment of 

survivor risk factors will become part of the bereavement 

care plan. Social workers and chaplains are to review this 

plan quarterly. What United calls core grief services include 

the following: grief counseling, home visits, bereavement 

group activities, volunteer support, patient/family education 

materials, quarterly follow-up/correspondence, memorial 

gatherings, sympathy cards, assistance with memorial 

services, community resources and referrals, staff 

bereavement support, and community education/relations. 

The applicant indicates that through the United Hospice 

Foundation (the Foundation), there are various bereavement 

care initiatives, with “Camp Cocoon” being the most 

significant, per the applicant. This is a three day 

bereavement camp for children ages five through 17 held 

each summer in north Georgia. The camp is designed to 

provide positive and creative outlets for children who have 

suffered the loss of a close loved one and is operated by 

volunteers, primarily employees of United. Some of these 

volunteers are stated to be physicians, nurses, social 

workers, Chaplains bereavement coordinators and others. 

The applicant indicates that Camp Cocoon will be made 

available to children grieving the loss of a loved one in 

Hospice Service Area 4A. However, the applicant does not 

condition that Camp Cocoon will be made available to the 

Hospice Service Area 4A population, nor does it condition for 

any given bereavement service activity, per se. 


states that staff and volunteers provide bereavement 

services, which according to the applicant are appropriate 

from the time of nursing assessment until mourning is 

accomplished and the survivor can emotionally reinvest into 

life and other relationships. The applicant provides three 

bereavement VITAS publications and materials 17 , including 

the 54-page, The Surviving Spouse (by J Richard Williams, 

MD), the 16-page Children & Grief and the 20-page Teens & 

93


Grief. The applicant indicates that while services are 

generally provided for one year (12 months) after the death of 

the patient, services will be available beyond one year, if 

needed, and this is conditioned. Support is stated to be 

available 24/7 through a toll-free phone number with a 

trained psychosocial staff person available. What VITAS 

calls core grief services include the following: grief 

counseling, home visits, bereavement group activities, 

volunteer support, patient/family education materials, 

quarterly follow-up/correspondence, memorial gatherings, 

sympathy cards, assistance with memorial services, 

community resources and referrals, staff bereavement 

support, and community education/relations. The 

bereavement program will be directed by a VITAS 

volunteer/bereavement manager and supported by a 

Chaplain. Features of the program are as follows: 

bereavement assessment, development of the bereavement 

plan of care, home visits, written contacts with family (at 

intervals of one, three, six, nine, 12 and 15 months), 

telephone contact, counseling, and referral. At the time of 

patient death, a bereavement packet is provided, an 

invitation to bereavement groups and memorial gatherings. 

There is also staff bereavement support. 

(l) Proposed community education activities concerning 

hospice programs. 


#10061) states that it tailors its services and program 

offerings to the unique needs of the communities in which it 

serves. Compassionate Care states that it is committed to 

providing community education activities concerning hospice 

programs to residents of Hospice Service Area 4A. The 

applicant states that most hospices market primarily to 

hospitals, nursing homes, assisted living operators and 

physicians. Reflective of this, the applicant conditions for a 

full time dedicated staff member, located in the City of 

Jacksonville (Duval County) to reach all five counties, with 

the exclusive responsibility of serving as a community 

outreach coordinator to the non-health care community. 

Schedule 6A specifically itemizes 1.0 FTE for a community 

liaison in year one and 1.5 FTE in year two. 

94


The applicant includes written education materials regarding 

hospice care specifically designed for health providers. The 

applicant conditions that it will conduct extensive 

community education and outreach programs, itemizing the 

groups it intends to target for education (CON Application 

#10061, Schedule C). 



conditions that it will have a minimum of three community 

education representatives, expanding community awareness 

of hospice services and educating local medical staff, 

community leaders and potential hospice patients as to the 

benefit of and availability of hospice care. Odyssey‟s 

Schedule 6A does not show FTEs for these positions. The 

applicant also conditions for various other educational 

programs, such as in-service training (components of 

Odyssey University) resources to the community, including 

nursing homes, assisted living facilities and the Council on 

Aging. Also conditioned are: in-service training to registered 

nurses, social workers, administrators and other staff, with 

the applicant conditioning to host at least one seminar 

annually during the first two years of operation for clergy 

and community faith leaders (The Clergy End of Life 

Education Program), to enhance spiritual support for 

hospice patients in the area. 


states the provision of hospice education through many 

venues: printed material, commercial spots on television and 

radio, articles in newspapers and magazines, testimonials in 

person at service clubs, women‟s clubs, churches, 

synagogues, schools, community colleges and universities. 

The applicant states that it will target hospitals, nursing 

homes and ALFs. Seasons states it is already a provider of 

continuing education credits for nurses. According to 

Seasons, it publishes, free of charge, a newsletter – “Seasons 

Hospice & Palliative Care”, “Guide for Patients Families and 

Friends/Enhancing the Quality of Time” and “Tender Legal 

Care”. Seasons states that it will integrate Hospice Service 

Area 4A into its main website (www.Seasons.org), to keep 

costs down and offer a uniform message, consistent with the 

applicant‟s mission and vision. This applicant conditions to, 

within six months of project final approval, donate $50,000 

(to the Clay County Board of County Commissioners) to 

95


promote outreach and education of hospice services. It also 

conditions to publish at least one edition of each newsletter 

(Seasons Hospice & Palliative Care and PharmSmart) by the 

end of the first year of operation. 

United Hospice of Florida, Inc. (CON #10064) plans a 

tailored African-American outreach program that will 

coordinate educational sessions, presentations and listening 

sessions. United Hospice staff is planned to educate nursing 

home and ALF constituents on myths and benefits of 

hospice. The applicant also plans to host hospice 

educational events at senior organizations, religious affiliated 

groups, Veterans organizations and health fairs and educate 

residents of rural areas of Baker and Nassau Counties and 

more. The applicant conditions for a staff member that is 

responsible for outreach initiatives to plan events and serve 

as a key contact with African-American community leaders. 

United‟s Schedule 6A shows 2.0 FTEs in year one and 3.0 

FTEs in year two for hospice representatives. The applicant 

conditions to sponsor two to four education seminars per 

year for physicians, long-term care facilities and ALFs. 


proposes to educate the service area through public forums, 

such as seminars and community education at churches, 

schools and other social organizations. The applicant 

identifies other specific organizations it would target for 

hospice education: the Florida Health Care Association, the 

Florida Assisted Living Association, the Florida Association 

Directors of Nursing Administration, American Legion, 

Veterans of Foreign Wars Chapter, local nursing homes, 

local ALFs and United Way, among others (not stated). The 

applicant plans to address education as it has done in its 

hospice operations in the following Florida hospice service 

areas: 4B, 7A, 7B, 7C, 8B, 9C, 10, and 11. Conditioned 

contributions to Florida State College at Jacksonville 

($300,000), United Way of Northeast Florida (up to 

$500,000) and the Jacksonville Urban League ($50,000) are 

all stated as mechanisms to educate the community about 

hospice. 

96

(m) Fundraising activities. 



states that it does not intend to engage to a great extent in 

fundraising to support its ongoing operations. Nonetheless, 

it participates in limited fundraising activities, primarily 

through bequests and family gifts, and makes use of such 

funding when appropriate, through the efforts and actions of 

its related Compassionate Care Hospice Foundation, Inc. 

(the Foundation), a non-profit organization stated to be 

based in Newark, Delaware. Compassionate Care states the 

Foundation is designed to provide financial assistance to 

terminally ill patients and families in need. Additionally, it 

supports public programs to provide the general public with 

information about the end-of-life choice so that individuals 

can determine and communicate their wishes and help their 

families prepare for the future. 

None of its funds are used for provision of direct hospice 

care; rather it is available to assist when financial difficulty 

overwhelms families and places them under untenable 

stress, per Compassionate Care. Compassionate Care 

Hospice Foundation provides services in instances that are 

typically not covered or reimbursed by insurance, according 

to the applicant. Compassionate Care states it will not 

compete with other extensive fund raising activities that are 

already well developed and important to support existing 

providers in the area; however, the applicant does not 

condition that it will refrain from active fundraising. 



states it will not perform any fundraising activities in direct 

support of its programs but will support existing communitybased 

fundraising efforts such as those of local health care 

support groups and the existing hospice provider (singular), 

as well as the fundraising of the parent‟s “Dream 

Foundation”. Per the applicant, through the parent (Odyssey 

Healthcare), the Odyssey VistaCare Hospice Foundation 

contributed nearly $5.8 Million in charity care in 2008 and 

more than $878,000 in 2007. The applicant does not 

condition that it will refrain active fundraising. 

97


The applicant conditions that through the parent (Odyssey 

HealthCare) or the Odyssey VistaCare Hospice Foundation a 

$25,000 contribution will be made to an appropriate not-forprofit 

entity in the community to fund education for end-oflife 

issues. 

The applicant offers numerous instances of nonreimbursable 

events and services provided by Odyssey 

HealthCare-Daytona. The applicant is non-specific on when 

the events took place and does not offer an estimate of the 

cumulative or individual costs of the services described. 


states it has a number of specialized programs and services 

that are not part of the benefits of Medicare, Medicaid or 

insurance but are nevertheless needed for palliative care at 

the end-of-life. Efficiency and volunteer time is stated to offset 

many of these costs. Seasons states it is in the process 

of developing a special non-profit foundation to 

accommodate donations and if the project is approved, when 

the non-profit foundation materializes, its resources would 

be made available for Hospice Service Area 4A use. The 

applicant states that fundraising for hospice is a 

combination of sponsorship, partnership, corporate and 

locally driven by appreciation. Seasons indicates donations 

are often given without being sought. The applicant does not 

affirmatively state, nor does it condition, that it will refrain 

from actively seeking donations through fundraising efforts. 

Seasons states that since it cannot count upon donations as 

a steady revenue stream, it works diligently to negotiate 

rates with insurers and other local and state programs to 

cover costs. 

United Hospice of Florida, Inc. (CON #10064) states that 

it does not actively raise funds from the community and 

therefore does not compete with non-profit hospice 

organizations or other groups in obtaining funds from the 

community; however, this is not conditioned. The applicant 

claims that as a result of not actively raising funds from the 

community, it will not dilute potential contributions 

available in the community or adversely impact existing 

hospice programs‟ fundraising efforts. The applicant states 

it will “give back” by conditioning CON approval to the 

following: providing hospice services to the homeless in 

shelters, monthly health screenings for the homeless and 

98

3. Statutory Review Criteria 


contributions of a $2,000 scholarship each year to four 

students who are studying nursing, pharmacy or therapy, 

and have an interest in end-of-life care. 


states it does not and will not actively raise funds or accept 

donations, from the community. VITAS is the only cobatched 

applicant to condition that it will refrain from this 

activity. The applicant states it encourages that such 

donations go to charities that support the hospice‟s mission 

or to the charity of the donator‟s choice. VITAS states that it 

will not dilute potential contributions available in the 

community or adversely impact existing hospice programs‟ 

fundraising efforts. 

a. Is need for the project evidenced by the availability, quality of care, 

accessibility and extent of utilization of existing health care 

facilities and health services in the applicant’s service area? 

ss. 408.035(1)(a) and (b), Florida Statutes. 

Need for an additional hospice program is evidenced by the availability, 

accessibility and extent to utilization of existing health care facilities and 

health services in this service area. The co-batched applicants are 

responding to published need of one hospice program in Hospice Service 

Area 4A. 

The following chart illustrates the increase in hospice admissions for the 

past five years, in Hospice Service Area 4A. As shown below, admissions 

have increased from 4,581 in the year ending June 30, 2004 to 5,783 in 

the year ending June 30, 2009. 

Hospice Admissions for Service Area 4A 

Fiscal Years 2004 – 2009 

Fiscal Year Admissions 

07/08 – 06/09 

07/07 – 06/08 

07/06 – 06/07 

07/05 – 06/06 

07/04 – 06/05 

07/03 – 06/04 

99 

5,783 

5,628 

5,064 

4,969 

4,763 

4,581 

Source: AHCA Florida Need Projections for Hospice Programs, Fiscal Years 2004-2009. 

Compassionate Care Hospice of Florida, Inc. (CON 10061) notes that 

three licensed hospice providers offer services in the hospice service area. 

This applicant also notes continued hospice admission growth from 2002


through 2009 and in the above table, the Agency verifies steady growth 

for each 12-month period since at least June 2004. The applicant 

proposes locate offices in the following three counties to meet demand: 

Duval, Clay, and St. Johns. The applicant justifies offices in Clay and St. 

Johns Counties by stating these are the second and third largest 

counties, respectively, by population, in the hospice service area. 

The applicant asserts that it is committed to providing the highest 

quality care possible to terminally ill patients and their families and will 

continue to respond to future needs of the community, as it has done at 

other locations in which it operates. 

The applicant provides the fewest number of local support letters, 

providing the weakest evidence of all co-batched applicants that it has 

local support to provide the hospice services it proposes in Hospice 

Service Area 4A. 


HealthCare of Central Florida (CON #10062) proposes “special and not 

normal” circumstances to justify its proposal, in addition to the Agency‟s 

published need. These specific terminally ill populations that the 

applicant has identified as not being adequately served are as follows: 

cancer patients age 65 years and older, non-cancer patients under the 

age of 65 years, and non-cancer patients age 65 years and older. The 

applicant also states that introduction of a new hospice in the area will 

improve quality of care through increased competition. 

One of the hallmarks of the applicant‟s stated increased quality is patient 

admission within three hours after receiving a physician‟s order for 

hospice care; however, the Agency notes that this is not conditioned by 

the applicant. Odyssey believes that its proposal to provide three or 

more dedicated community education representatives will significantly 

increase public awareness of the benefits of hospice services. Odyssey 

also states intentions to be cost-effective, have a level of patient-focused 

care not currently available to the Hospice Service Area 4A and will 

expand the existing hospice market to reach a wider base of patients 

(through service-based competition). The applicant also focuses on 

disaster planning and promotes “green” initiatives to be more 

environmentally friendly. Odyssey and co-batched applicant Seasons 

Palliative Care of Florida, Inc. (CON #10063) are the only two of the cobatched 

applicants that do not state that rural residents of the hospice 

service area lack access to and availability of hospice care. This is the 

only co-batched applicant that states that all diagnostic groups are 

underserved. The applicant does condition for hospice services 

specifically designed for the Hispanic population (and other minorities 

100


not specified) and is the only co-batched applicant to condition for 

serving the Hispanic population but lacks any support letters from local 

or regional/state or national Hispanic organizations. The applicant‟s 

CareBeyond Program, a system designed to tailor plans of care specific to 

given diagnoses, is a feature of this applicant. The applicant believes 

efficiency will be improved by the overall weight of the parent‟s 

experience and size on a nationwide basis. 

Seasons Palliative Care of Florida, Inc. (CON #10063) states that 

overall, hospice services are only palliative and are delivered at the endof-life 

to meet hospice patient needs. Seasons indicates that as hospices 

have closed in the area over the past several years, hospice patient 

growth has continued. Seasons challenges that self-reporting of 

measures and outcomes is adequate to form conclusions about hospice 

services in the local area and that generally, access, availability and 

quality of care are questionable when self-reported. As such, Seasons 

reports it is an advocate of external accreditation, such as by the Joint 

Commission, with trained surveyors, with consistently applied standards 

and measures. In this way, Seasons states it can assure the public of 

meeting rigorous standards as assessed by external reviewers. Seasons 

proposes a condition to work with the Agency and the Department of 

Elder Affairs to develop and field test hospice outcome measures that will 

further enhance the data collected and promote program performance 

throughout the state. The cost of this endeavor will be borne by the 

applicant. 

United Hospice of Florida, Inc. (CON #10064) states a projected net 

need of 925 additional hospice program admissions for the January 2011 

Hospice Planning Horizon and that the most significant gap in hospice 

services is within non-cancer patients, with particular recognition of noncancer 

patients under 65 years of age. In addition to non-cancer 

patients, this applicant also targets other stated underserved populations 

in the area – African-Americans, the homeless, the mentally ill and rural 

residents of the area. The applicant conditions to reach each of these 

populations. The applicant also conditions for main offices in the City of 

Jacksonville, with satellites in Baker and Nassau Counties, to 

particularly reach the populations the applicant finds to currently have 

the least hospice access and availability. The applicant also finds that 

the UHS-Pruitt family of companies will be best suited to be a fully 

integrated model of care where patients can be most efficiently and easily 

transitioned as their hospice needs change, offering seamless support. 

VITAS Healthcare Corporation of Florida (CON #10065) states that its 

operations would not materially impact volume at the existing hospices 

in the area. VITAS states that as a matter of state policy, the need for an 

101


additional hospice project in the area is evidenced by the extent of 

utilization of existing hospice services in the area. The applicant 

conditions to reach the populations it identifies as most lacking hospice 

access and availability, that being terminally-ill non-cancer patients, 

African Americans and rural Baker County. VITAS like co-batched 

applicant Odyssey Healthcare of Collier County, Inc. (CON #10062) 

states that it incorporates disaster planning into its operations. In 

summary, the applicant states more experience providing hospice 

services in Florida and nationwide than any co-batched applicant. VITAS 

has the widest range of local and state-affiliated support letters of all cobatched 

applicants that propose to provide hospice services in Hospice 

Service Area 4A. 

b. Does the applicant have a history of providing quality of care? Has 

the applicant demonstrated the ability to provide quality care? ss. 

408.035 (1) (c), Florida Statutes. 

Compassionate Care Hospice of Florida, Inc. (CON #10061) states it is 

a newly formed entity and therefore has no operational history. However, 

Compassionate Care states origination in 1993 and operation or approval 

to operate in the following 16 states: Delaware, Florida (will become 

operational in February 2010); Georgia, Illinois, Kansas, Massachusetts, 

Michigan, Minnesota, Missouri, Nebraska, New Jersey, New York, 

Pennsylvania, South Dakota, Texas, and Wisconsin. 

The applicant includes copies of policies and procedures (CON 

Application #10061, Appendix S-Policies & Procedures) that address a 

wide range of hospice practices. Some of these policies and procedures 

include: incident reporting, clinical record review, summary satisfaction 

surveys, condition of participation forms, annual evaluation, orientation, 

continuous care services, interdisciplinary team plan, complaint/ 

grievance procedures, initial/comprehensive assessment, and many 

others. Compassionate Care states its performance improvement plan is 

incorporated within Medicare conditions of participation, as required by 

Florida licensure rules. Compassionate Care states it has extensive 

benchmarking and also attests to close monitoring and collection of 

measurable data on 15 separate events. Some of these include: 

medication errors, adverse drug reactions, patient falls, 911 calls, 

infection control, pain assessment and control review, satisfaction 

surveys, comfort within 48 hours of admission, and performance 

improvement. This applicant does not condition for seeking Joint 

Commission accreditation. 

102



HealthCare of Central Florida/CON #10062 (Odyssey or OHCCF) is 

the sole shareholder of Odyssey HealthCare Operating B, LP, a wholly 

owned subsidiary of Odyssey. The parent is stated to have 92 Medicarecertified 

hospice programs spread among 29 states. The parent‟s 

existing Florida hospice programs (Odyssey HealthCare-Daytona and 

Odyssey HealthCare-Miami/Dade) are stated to have an ADC of 111.7 

and 288 patients, respectively over the 10-month period ending October 

2009. Odyssey HealthCare-Daytona and Odyssey HealthCare- 

Miami/Dade have over 34,000 and 79,000 patient days, respectively, 

over the same period. The applicant states that Odyssey has received the 

Pioneer Award, the GM Circle of Excellence Award and the Mission 

Award. If CON approved, the applicant anticipates establishing and 

operating a hospice program in Hospice Service Area 4AB, with the speed 

and efficiency that it did when approved to operate hospice programs in 

Hospice Service Areas 4B and 11. The applicant states that Odyssey 

hospice programs are members of the National Hospice and Palliative 

Care Organization, and are Medicare and Medicaid certified or are 

pursuing said certification. The applicant says it will adopt and practice 

the same standards of quality and efficiency that are promoted by the 

parent. The applicant conditions that it will become accredited by the 

Joint Commission and the National Institute for Jewish Hospice by the 

end of its second year of operation. 

For the three-year period ending January 15, 2010, the parent‟s Odyssey 

HealthCare-Daytona and Odyssey HealthCare-Miami/Dade have one 

confirmed complaint, per Agency records. The confirmed complaint is 

medicine problem/error/formulary. 

Seasons Palliative Care of Florida, Inc. (CON #10063) is a Florida forprofit 

corporation and development stage company formed on October 

29, 2009 for the purpose of operating a hospice in Florida. Seasons 

states it admitted 9,290 persons during the 12-month period ending 

October 31, 2009. 

The applicant reports a quality assessment and performance 

improvement program, to reflect the complexity of the organization and 

its services, including services provided by contract (CON Application 

#10063, Exhibit 4-1/Overview of Policy and Procedures for Quality 

Assessment & Performance Improvement and Sentinel Events). The 

103


applicant also provides currently active Joint Commission accreditation 

certificates for its affiliate hospice operations in the following states: 

Delaware, California, Illinois, and Texas. No other co-batched applicant 

offers Joint Commission certifications. The applicant conditions that 

within the first two years of operation Seasons will begin the preparatory 

activities to be accredited by the Joint Commission. 

United Hospice of Florida, Inc. (CON #10064) states it is a newly 

formed corporation and therefore has no operating history. However, the 

applicant is a wholly owned subsidiary of United Health Services of 

Florida, Inc., a member of the UHS-Pruitt family of companies. United 

reports owning 25 hospices throughout the Southeast (in the states of 

Georgia, North Carolina and South Carolina). Per the applicant, UHS 

has a strong demonstrated history of providing high quality of care, with 

a reported regulatory compliance history of no deficiencies in conditions 

of Medicare participation, no Medicare CAP issues, has never been 

investigated by an OIG and has never had to adhere to court ordered 

corporate integrity agreements. United states that in 2002, UHS 

committed to the Quality First Pledge, which the applicant states is 

rooted in seven different principles that cultivated an environment of 

continuous quality improvement, openness/transparency and 

leadership. UHS states support for the American Health Care 

Association's definition of quality: the totality of features and 

characteristics of services that meet or exceed customer expectation and 

need. UHS states an expectation of quality to be reflective of its 

performance in the delivery of health care services each and every day. 

The applicant expects to be an innovator in a seamless and superior 

health care delivery system to the community it serves. The applicant 

claims adherence to the United Hospice quality assessment/performance 

improvement plan [CON Application #10064, Tab 17]. United Hospice 

conditions that it will seek and obtain CHAP accreditation upon 

certification. 

VITAS Healthcare Corporation of Florida (CON #10065) is a for-profit 

operating entity in Florida. VITAS states it has provided hospice services 

since 1978, has an average daily census of 4,547 patients and serves 

more than 16,000 patients and family annually. VITAS has licensed 

hospice programs in the following eight Florida hospice service areas: 4B 

(Flagler and Volusia Counties), 7A (Brevard County), 7B (Orange and 

Osceola Counties), 7C (Seminole County), 8B (Collier County), 9C (Palm 

Beach County), 10 (Broward County), and 11 (Miami-Dade and Monroe 

Counties). 

104


VITAS states its quality assurance program is designed to meet and, in 

many cases, exceed those standards established by regulatory bodies. 

Program standards as developed by the National Hospice and Palliative 

Care Organization are stated to serve as the basis for all program 

components at VITAS. The purpose of the applicant‟s QI Program is to 

assure the provision of high quality patient and family care through the 

ongoing monitoring and evaluation of the quality, availability and 

appropriateness of the hospice services and therapies provided by VITAS. 

For the three-year period ending January 15, 2010, the VITAS family of 

Florida hospice operations spread throughout Hospice Service Areas 4B, 

7A, 7B, 7C, 8B, 9C, 10 and 11 have four confirmed complaints. The four 

confirmed complaints are one each for the following: discharge planning, 

lack of assessment, medicine problems/errors/formulary and nursing 

services. 

c. What resources, including health manpower, management 

personnel, and funds for capital and operating expenditures, are 

available for project accomplishment and operation 

ss. 408.035(1)(d), Florida Statutes. 

Compassionate Care Hospice of Florida, Inc. (CON 10061): The 

financial impact of the project will include the project cost of $227,616 

and incremental operating costs in year two of $4,236,244. The 

applicant is a Florida for-profit corporation and a development stage 

company that was formed on September 19, 2007 for the purpose of 

operating a hospice in Florida, with net assets of $40,000 and $49,900 in 

liabilities for the period ended December 15, 2009. At the date of the 

audit, no operating results were available. Without results from 

operations, an analysis of the short and long-term strength of the 

applicant cannot be made. 

Capital Requirements: 

Schedule 2 indicates total capital projects of $1,020,075 which consist of 

the CON subject to this review, CON #10000 for a hospice in District 4B, 

and $500,000 in other capitalization. In addition, the applicant will have 

to fund the projected year one operating loss of $330,083. 

Available Capital: 

The applicant provided a letter from its parent corporation, 

Compassionate Care Hospice Group, Ltd. which states it will provide 

funding for the project. In support of this statement, the applicant 

provided a letter from JPMorgan showing a $1,500,000 line of credit, and 

indicates that the entire line of credit is available to the parent. It should 

be noted that the applicant included operating results of its parent. 

105


Because the parent‟s operating results were unaudited, the Agency did 

not consider them in this review. 

Staffing: 

Schedule 6A indicates for year one ending June 30, 2011, the applicant 

forecasts 34.9 FTEs as follows: administration, 5.5 FTEs; physicians, 0.3 

FTEs; nursing, 24.6 FTEs; ancillary, 1.0 FTEs; dietary 0.5 FTEs and 

social services, 3.0 FTEs. In the second year ending June 30, 2012 the 

applicant forecasts 52.1 FTEs as follows: administration, 7.0 FTEs; 

physicians, 0.6 FTEs; nursing, 39.0 FTEs; ancillary, 1.0 FTEs; dietary 

0.0 FTEs and social services, 4.5 FTEs. 

Conclusion: 

Funding for the project should be available as needed. 


HealthCare of Central Florida (CON #10062): The financial impact of 

the project will include the project cost of $666,972 and incremental 

operating costs in year two of $2,650,443. The applicant is a Florida forprofit 

corporation, incorporated on October 18, 2006, for the purpose of 

operating a hospice and related businesses in the State of Florida. As of 

December 31, 2008, the applicant had no assets and $227,731 in 

liabilities, with $227,731 operating loss. This amount is an intercompany 

payable. 

The applicant provided audited financial statements of its ultimate 

parent company and subsidiaries, Odyssey Healthcare, Inc., a for-profit 

corporation, for the periods ending December 31, 2008 and 2007. These 

statements were analyzed for the purpose of evaluating the parent‟s 

ability to provide the capital and operational funding necessary to 

implement the project. 

Short-Term Position: 

The parent‟s current ratio of 1.7 indicates current assets are over oneand-a-half 

times the current obligations, this is slightly below average 

and an adequate position. The working capital of $82.4 million is a 

measure of excess liquidity that could be used to fund capital projects. 

The ratio of cash flow to current liabilities of 0.2 is well below average 

and a weak position. Overall, the parent has a slightly weak but 

adequate short-term position. (See Table below). 

106


Long-Term Position: 

The ratio of long-term debt to net assets of 0.7 is above average and 

indicates the parent may have difficulty obtaining additional debt 

financing if needed. The ratio of cash flow to assets of 4.6 percent is 

below average and a weak position. The most recent year had $30.8 

million in operating income, which resulted in a 5.0 percent operating 

margin. Overall, the applicant has a slightly weak but adequate longterm 

position. (See Table below). 

Odyssey Healthcare, Inc. and Subsidiaries 

107 

12/31/2008 

Current Assets (CA) $207,323,000 

Cash and Current Investment $56,043,000 

Total Assets (TA) $460,951,000 

Current Liabilities (CL) $124,894,000 

Total Liabilities (TL) $260,880,000 

Net Assets (NA) $200,071,000 

Total Revenues (TR) $616,050,000 

Interest Expense (IE) $7,430,000 

Operating Income (OI) $30,819,000 

Cash Flow from Operations (CFO) $21,049,000 

Working Capital $82,429,000 

FINANCIAL RATIOS 

12/31/2008 

Current Ratio (CA/CL) 1.7 

Cash Flow to Current Liabilities (CFO/CL) 0.2 

Long-Term Debt to Net Assets (TL-CL/NA) 0.7 

Times Interest Earned (OI+IE/IE) 5.1 

Net Assets to Total Assets (NA/TA) 43.4% 

Operating Margin (OI/TR) 5.0% 

Return on Assets (OI/TA) 6.7% 

12/31/2007 

$151,455,000 

$62,179,000 

$275,209,000 

$76,180,000 

$92,372,000 

$182,837,000 

$398,232,000 

$208,000 

$24,000,000 

$12,814,000 

$75,275,000 

12/31/2007 

2.0 

0.2 

0.1 

116.4 

66.4% 

6.0% 

8.7% 

Operating Cash Flow to Assets (CFO/TA) 4.6% 4.7% 



the CON subject to this review, CON #10068 for a hospice in District 5B, 

and CON #10071 for a hospice in District 7B. The applicant is projecting 

a year one operating loss of $706,918. The applicant will have to fund 

the year one operating loss until profitability can be reached.



Funding for this project will be provided by the parent. The parent has 

working capital of $82.4 million and $30.8 million in operating income. 

In addition, cash flow from operations was $21.0 million. The project 

would only represent 0.81 percent of the parent‟s working capital and 

3.17 percent of operating cash flows. 

Staffing: 

Schedule 6A indicates for year one ending December 31, 2011, the 


physicians, 0.1 FTEs; nursing, 4.2 FTEs; ancillary, 1.9 FTEs; dietary 0.1 

FTEs and social services, 0.8 FTEs. In the second year ending December 

31, 2012 the applicant forecasts 25.0 FTEs as follows: administration, 

7.7 FTEs; physicians, 0.1 FTEs; nursing, 6.0 FTEs; ancillary, 2.6 FTEs; 

dietary 0.1 FTEs and social services, 0.8 FTEs. 

Conclusion: 

Funding for this project should be available as needed. 

Seasons Palliative Care of Florida, Inc. (CON #10063): The financial 

impact of the project will include the project cost of $658,585 and 

incremental operating costs in year two of $7,658,900. The applicant is 

a Florida for-profit corporation and a development stage company that 

was formed on October 29, 2009 for the purpose of operating a hospice 

in Florida, with net assets of $1,050,000 and $10,000 in liabilities for the 

period ended November 30, 2009. The cash balance of $1,050,000 

represents the proceeds from issuing common stock. At the date of the 

audit, no operating results were available. Without results from 

operations, an analysis of the short and long-term strength of the 

applicant cannot be made. 


Schedule 2 indicates total capital projects of $658,585 which is the CON 

subject to this review. It should be noted that among the applicant‟s 

conditions, two conditions indentified a need for specific funds. Funding 

for those conditions is included in the capital budget on Schedule 2. In 

addition, the applicant will have to fund the projected year one operating 

loss of $355,500. 


The applicant provided audited financial statements as of November 30, 

2009 showing $1,050,000 in cash with virtually no liabilities. 

108


Staffing: 

Schedule 6A indicates for year one ending December 31, 2011, the 


physicians, 0.0 FTEs; nursing, 23.25 FTEs; ancillary, 0.0 FTEs; dietary 

0.75 FTEs and social services, 5.42 FTEs. In the second year ending 

December 31, 2012, the applicant forecasts 62.85 FTEs as follows: 

administration, 17.0 FTEs; physicians, 0.0 FTEs; nursing, 36.76 FTEs; 

ancillary, 0.0 FTEs; dietary 1.17 FTEs and social services, 7.92 FTEs. 

Conclusion: 


United Hospice of Florida, Inc. (CON #10064): The financial impact of 

the project will include the project cost of $251,233 and incremental 

operating costs in year two of $5,415,021. The applicant is a Florida forprofit 

corporation, incorporated on October 16, 2009, for the purpose of 

operating a hospice and related businesses in the State of Florida. As of 

November 25, 2009, the applicant had $10,000 in assets and $9,000 in 

liabilities, with no operations. 

The applicant provided audited financial statements of its ultimate 

parent company and subsidiaries, United Health Services, Inc., a forprofit 

corporation, for the periods ending June 30, 2009 and 2008. 

These statements were analyzed for the purpose of evaluating the 

parent‟s ability to provide the capital and operational funding necessary 

to implement the project. 


The parent‟s current ratio of 0.9 indicates current assets are less than 

current obligations. This is below average and a weak position. This 

results in a working capital deficit of $14.2 million. The ratio of cash 

flow to current liabilities of 0.4 is below average and a weak position. 

Overall, the parent has a weak short-term position. (See Table below). 


The ratio of long-term debt to net assets of 3.4 indicates the parent is 

highly leveraged and may have difficulty obtaining additional debt 

financing if needed. The ratio of cash flow to assets of 11.9 percent is 

well above average and a good position. The most recent year had $16.9 

million in operating income, which resulted in a 2.9 percent operating 

margin. Overall, the applicant has a slightly weak but adequate longterm 

position. (See Table below). 

109


The weak short and long-term position of the parent appears to be the 

result of cash and debt used to make a number of health care facility 

acquisitions. The subsequent events note in the audit indicates that the 

parent entered into four additional health care facility acquisitions after 

the fiscal year end date. 

United Health Services, Inc. & Subsidiaries 

110 

6/30/2009 


Cash and Current Investment $5,433,573 




Net Assets (NA) $54,700,650 


Interest Expense (IE) $9,805,656 



Working Capital ($14,206,609) 


6/30/2009 




Times Interest Earned (OI+IE/IE) 2.7 




6/30/2008 

$80,304,743 

$2,609,207 

$285,565,941 

$85,137,811 

$244,469,013 

$41,096,928 

$518,137,965 

$11,139,539 

$12,512,127 

$21,188,644 

($4,833,068) 

6/30/2008 

0.9 

0.2 

3.9 

2.1 

14.4% 

2.4% 

4.4% 



Schedule 2 indicates total capital projects of $532,595 which consist of 

the CON subject to this review and CON #10072 for a hospice in District 

7B. The applicant is projecting a year one operating loss of $438,171. 

The applicant will have to fund the year one operating loss until 

profitability can be reached. 


According to the application, the parent will fund this project through 

operating cash flows. The parent‟s audited financial statements indicate 

cash flow from operations was $39.8 million. Although the parent shows


weakness in both the short and long-term, this project, including 

funding the year one operating loss, would only represent 1.73 percent of 

operating cash flows. 

Staffing: 

Schedule 6A indicates for year one, the applicant forecasts 16.97 FTEs 

as follows: administration, 17.5 FTEs; physicians, 0.0 FTEs (by contract); 

nursing, 7.14 FTEs; ancillary, 0.0 FTEs (by contract); dietary 1.0 FTEs 

and social services, 1.33 FTEs. In the second year, the applicant 

forecasts 44.35 FTEs as follows: administration, 11.58 FTEs; physicians, 

0.0 FTEs (by contract); nursing, 28.59 FTEs; ancillary, 0.0 FTEs (by 

contract); dietary 1.0 FTEs and social services, 3.17 FTEs. 

Conclusion: 


VITAS Healthcare Corporation of Florida (CON #10065): The financial 

impact of the project will include the project cost of $338,353 and 

incremental operating costs in year two of $3,676,111. 

The Agency reviewed the audited financial statements of the applicant (a 

Florida for-profit corporation) for the periods ending December 31, 2008 

and 2007. These statements were analyzed for the purpose of evaluating 

the applicant‟s ability to provide the capital and operational funding 

necessary to implement the project. 


The applicant‟s current ratio of 2.0 indicates current assets are two times 

more than current obligations. This is slightly below average and an 

adequate position. The working capital of $18.5 million is a measure of 

excess liquidity that could be used to fund capital projects. The ratio of 

cash flow to current liabilities of 1.7 is well above average and a strong 

position. Overall, the applicant has good short-term position. (See Table 

below). 


The ratio of long-term debt to net assets of 0.4 is below average and 

indicates the applicant has sufficient equity to acquire additional debt if 

needed, a good position. The ratio of cash flow to assets of 16.2 percent 

is well above average and a good position. The most recent year had 

$48.5 million in operating income, which resulted in a 15.8 percent 

operating margin. Overall, the applicant has a good long-term position. 

(See Table below). 

111


VITAS Healthcare Corporation of Florida 

112 

12/31/2008 


Cash and Current Investment $3,998 




Net Assets (NA) $128,783,630 


Interest Expense (IE) $0 



Working Capital $18,538,636 


12/31/2008 




Times Interest Earned (OI+IE/IE) #DIV/0! 




12/31/2007 

$36,137,101 

$3,998 

$197,890,693 

$18,490,669 

$99,100,043 

$98,790,650 

$281,340,731 

$0 

$46,700,627 

$22,720,506 

$17,646,432 

12/31/2007 

2.0 

1.2 

0.8 

#DIV/0! 

49.9% 

16.6% 

23.6% 




the CON subject to this review and other capitalization. The applicant is 

projecting a year one operating loss of $457,514. The applicant will have 

to fund the year one operating loss until profitability can be reached. 


Schedule 2 indicates that funding for this project will be provided by the 

applicant‟s cash flows from operations. The applicant has working 

capital of $18.5 million and cash flow from operations of $32.2 million. 

The applicant listed several conditions in its application that included a 

financial impact in particular several charitable contributions totaling 

$850,000. It is not clear from the information provided that these 

contributions were included in the capital cost or projected operations. 

However, it appears that the applicant has sufficient capital available to 

meet the charitable conditions proposed.


Staffing: 

Schedule 6A indicates for year one, ending June 2011, the applicant 


0.32 FTEs; nursing, 9.86 FTEs; ancillary, 0.0 FTEs (by contract); dietary 

0.0 FTEs (per assumptions a part of VITAS services) and social services, 

2.64 FTEs. In the second year, ending June 2012, the applicant 


0.85 FTE); nursing, 26.6 FTEs; ancillary, 0.0 FTEs (by contract); dietary 

0.0 FTEs (per assumptions a part of VITAS services) 18 and social 

services, 3.71 FTEs. 

Conclusion: 

Funding for this project and the entire capital budget should be available 

as needed. 

d. What is the immediate and long-term financial feasibility of the 

proposal? ss. 408.035 (1)(f), Florida Statutes. 

Compassionate Care Hospice of Florida, Inc. (CON 10061): For year 

two of operations, the applicant projects Medicare at 85.0 percent, 

Medicaid at 4.7 percent, self-pay/charity at 1.9 percent, and commercial 

insurance at 8.3 percent. 

The applicant indicated on Schedule 7 that it intends to provide routine 

home care, continuous home care, inpatient respite, and general 

inpatient care, and for which the Department of Health and Human 

Services sets rates. The federal rates were calculated for the Duval 

County, Florida Wage Index for Medicare Hospice payments of 0.9499 

and inflated through June 2012. The average price adjustment factor 

used was 2.8 percent per year based on the new CMS Market Basket 

Price Index as published in the 1st Quarter 2009 Health Care Cost 

Review. 

Estimated patient days for each level of service from Schedule 7, year two 

were multiplied by the calculated reimbursement rate for that service in 

order to estimate the total revenue that would be generated by that 

number of patient days. The results were then compared to the 

applicant‟s estimated gross revenue. The results of the calculations are 

summarized in the Table below. 

18 CON Application #10065, Schedule 6A - Summary of Significant Assumptions indicates that VITAS 

uses certified staff dieticians as needed. 

113


The applicant calculated continuous care revenues based on 16 hours of 

care rather than 24 hours. The applicant indicated that due to death or 

other causes, some patients will not, however, receive 24 hours of 

continuous care and will not, therefore, be eligible for reimbursement for 

a given day. In Agency calculation, staff made the same adjustment of a 

partial 16 hour payment. Based on Agency calculation, the applicant‟s 

projected gross revenue was -3.42 percent, or $164,792, less than the 

calculated gross revenue. The difference is primarily the result of 

contractual adjustments and is therefore, not considered material. 

Operating profits from this project are expected to increase from a loss of 

$330,083 for year one to a profit of $286,993 for year two. 

Conclusion: 

This project appears to be financially feasible. 

HOSPICE REVENUE TABLE 

CON #10061 Compassionate Care Hospice of Florida, Inc. 

Wage Index for Duval County(.9499) 

Wage 

Component Wage Index 

114 

Adjusted 

Wage 

Amount 

Unadjusted 

Component 

Payment 

Rate 

Routine Home Care $98.19 0.9499 $93.27 $44.72 $137.99 

Continuous Home Care $573.11 0.9499 $544.40 $260.99 $536.92** 

Inpatient Respite $80.02 0.9499 $76.01 $67.81 $143.82 

General Inpatient $406.94 0.9499 $386.55 $228.80 $615.35 

Payment 

Rate 

Inflation 

Factor Year 

Two 

Inflation 

Adjusted 

Amount 

Patient 

Days, June 

Year Two - 

2012 

Calculated 

Gross 

Revenue 

Routine Home Care $137.99 1.049 $144.74 30,685 $4,441,210 

Continuous Home Care $536.92 1.049 $563.17 491 $276,516 

Inpatient Respite $143.82 1.049 $150.85 39 $5,883 

General Inpatient $615.35 1.049 $645.43 407 $262,690 

Total 31,622 $4,986,300 

From Schedule 7 $4,821,508 

Difference 

-$164,792 

Percentage difference -3.42% 

** Continuous Home Care is calculated based on 16 hours of care rather than 24 hours.



HealthCare of Central Florida (CON #10062): For year two of 

operations, the applicant projects Medicare at 93.0 percent, Medicaid at 

3.0 percent, self-pay/charity at 2.0 percent, and managed 

care/commercial insurance at 2.0 percent. 

The applicant indicated on Schedule 7 that the service it intends to 

provide is routine home care, continuous home care, general inpatient 

care, and inpatient respite, and for which the Department of Health and 

Human Services sets rates. The federal rates were calculated for the 

Duval County, Florida Wage Index for Medicare Hospice payments of 

0.9499 and inflated through December 2012. The average price 

adjustment factor used was 2.9 percent per year based on the new CMS 

Market Basket Price Index as published in the 1st Quarter 2009 Health 

Care Cost Review. 







The applicant offered 26 conditions to its proposed hospice program. 

Several of these conditions would likely have a financial impact on the 

applicant. Based on the notes accompanying the projections, it appears 

that the applicant has taken into consideration the costs associated with 

the proposed conditions in the financial projections. 

The applicant‟s projected gross revenue was 3.39 percent, or $96,149, 

slightly less than the calculated gross revenue. The applicant used a 

lower inflation rate (2.0 percent) which is a conservative assumption. 

When the difference in inflation rates are considered, the difference in 

revenue projected is not deemed material. Operating profits from this 

project are expected to increase from a loss of $706,918 for year one to a 

profit of $78,063 for year two. 

Conclusion: 

This project appears to be financially feasible. 

115


CON #10062 Odyssey Healthcare of Collier County, Inc. 



Wage 


116 

Adjusted 

Wage 

Amount 

Unadjusted 

Component 

Payment 

Rate 


Continuous Home Care $573.11 0.9499 $544.40 $260.99 $805.39 



Payment 

Rate 

Inflation 

Factor Year 

Two 

Inflation 

Adjusted 

Amount 

Patient Days 

Year Two, 

December 

31 -2012 

Calculated 

Gross 

Revenue 





Total 17,123 $2,930,091 


Difference 

-$96,149 


Seasons Palliative Care of Florida, Inc. (CON #10063): For year two of 


4.0 percent, self-pay/charity at 0.5 percent, and commercial insurance 

and other payers at 7.5 percent. 


provide is routine home care, continuous home care, inpatient respite, 

and general inpatient care, and for which the Department of Health and 



0.9499 and inflated through June 2012. The average price adjustment 

factor used was 2.8 percent per year based on the new CMS Market 

Basket Price Index as published in the 1st Quarter 2009 Health Care 

Cost Review. 

The applicant did not provide a table with patient days by level of care 

(routine home, continuous home, inpatient respite, and general inpatient 

care). Therefore, estimated revenues for each level of service from 

Schedule 7, year two were divided by the calculated reimbursement rate


for that service in order to estimate the total patient days that would be 

generated by that level of revenue. The results were then compared to 

the applicant‟s estimated number of patient days. The results of the 

calculations are summarized in the Table below. 

The applicant‟s projected patient days were 2.7 percent or 938 days more 

than the calculated patient days. The applicant indicated using a 2.0 

percent inflation rate. If the Agency uses the same inflation rate as the 

applicant, the difference in calculated days is immaterial. Operating 

profits from this project are expected to increase from an operating loss 

of $355,500 for year one to an operating profit of $496,300 for year two. 

Conclusion: This project appears to be financially feasible. 


CON #10063 Seasons Palliative Care of Florida, Inc. 


Wage 


117 

Adjusted 

Wage 

Amount 

Unadjusted 

Component 

Payment 

Rate 


Continuous Home Care $573.11 0.9499 $544.40 $260.99 $805.39 



Payment 

Rate 

Inflation 

Factor Year 

Two 

Inflation 

Adjusted 

Amount 

Gross 

Revenue 

Year Two, 

Dec-2011* 

Calculated 

Medicare 

Patient 

Days 

Routine Home Care $137.99 1.064 $146.80 $4,718,600 32,142 

Continuous Home Care $805.39 1.064 $856.83 $202,300 236 

Inpatient Respite $143.82 1.064 $153.01 $6,200 41 

General Inpatient $615.35 1.064 $654.66 $784,000 1,198 

Total $5,711,100 33,616 

From Schedule 7 34,554 

Difference 

938 

Percentage difference 2.71%


United Hospice of Florida, Inc. (CON #10064): For year two of 


5.0 percent, charity at 1.0 percent, and commercial insurance at 1.5 

percent. 









Cost Review. 







The applicant calculated continuous care revenues based on 16 hours of 

care rather than 24 hours. The applicant indicated that due to death or 

other causes, some patients will not, however, receive 24 hours of 

continuous care and will not, therefore, be eligible for reimbursement for 

a given day. In our calculation, we made the same adjustment of a 

partial 16-hour payment. Based on the Agency‟s calculation, the 

applicant‟s projected gross revenue was 2.78 percent, or $151,394, less 

than the calculated gross revenue. Understating revenue is a 

conservative assumption and therefore reasonable. Operating profits 

from this project are expected to increase from a loss of $438,171 for 

year one to a profit of $598,144 for year two. 


118


CON #10064 United Hospice of Florida, Inc. 



Wage 


119 

Adjusted 

Wage 

Amount 

Unadjusted 

Component 

Payment 

Rate 





Payment 

Rate 

Inflation 

Factor Year 

Two 

Inflation 

Adjusted 

Amount 

Patient Days 

Year Two, 

December 31 

-2012 

Calculated 

Gross 

Revenue 





Total 33,852 $5,594,626 


Difference 

** Continuous Home Care is calculated based on 16 hours of care rather than 24 hours. 

-$151,394 


VITAS Healthcare Corporation of Florida (CON #10065): For year two 

of operations, the applicant projects Medicare at 92.0 percent, Medicaid 

at 5.0 percent, charity at 1.0 percent, and commercial insurance at 2.0 

percent. 









Cost Review.








The applicant calculated continuous care revenues based on 15.5 hours 

of care rather than 24 hours. Due to death or other causes, some 

patients will not receive 24 hours of continuous care and will not, 

therefore, be eligible for full reimbursement for a given day. In the 

Agency‟s calculation, staff made the same adjustment of a partial 15.5 

hour payment. Based on Agency calculation, the applicant‟s projected 

gross revenue was -2.26 percent, or $84,492, less than the calculated 

gross revenue. Some of this difference is due to the applicant using a 

lower rate of inflation than 2.8 percent rate used in our analysis. Using 

a lower inflation rate is a conservative assumption and therefore 

reasonable. It should be noted that the applicant included Inpatient 

Respite days with Routine Home Care days. Inpatient Respite is typically 

a relatively low volume activity for a Hospice and the difference in 

reimbursement rates is relatively small. Operating profits from this 

project are expected to increase from a loss of $457,514 for year one to a 

profit of $28,692 for year two. 


120


CON #10065 VITAS Healthcare Corporation of Florida 



Wage 


121 

Adjusted 

Wage 

Amount 

Unadjusted 

Component 

Payment 

Rate 





Payment 

Rate 

Inflation 

Factor Year 

Two 

Inflation 

Adjusted 

Amount 

Patient Days 

Year Two, 

June 11 - 

2012 

Calculated 

Gross 

Revenue 



Inpatient Respite $143.82 1.049 $150.85 0 $0 


Total 21,661 $3,826,717 


Difference 

-$84,492 


** Continuous Home Care is calculated based on 15.5 hours of care rather than 24 hours. 

e. Will the proposed project foster competition to promote quality and 

cost-effectiveness? ss. 408.035(1)(e) and (g), Florida Statutes. 

Each co-batched applicant is applying for a new hospice program to be 

located in Hospice Service Area 4A that currently has three existing 

hospice programs. Therefore, each co-batched applicant is offering a 

new choice of provider in the hospice service area. 

The impact of the price of services on consumer choice is limited to the 

payer type. Most consumers do not pay directly for hospice services 

rather they are covered by a third-party payer. The impact of price 

competition would be limited to third-party payers that negotiate price 

for services, namely managed care organizations. Therefore, price 

competition is limited to the share of patient days that are under 

managed care plans.


Compassionate Care Hospice of Florida, Inc. (CON 10061): The 

applicant is projecting 8.3 percent of its patient days from managed 

care/commercial insurance payers with 89.7 percent of patient days 

expected to come from fixed price government payer sources (Medicare 

and Medicaid), with the remaining 1.9 percent as self-pay/charity. 


HealthCare of Central Florida/CON #10062 (Odyssey or OHCCF): 

The applicant is projecting 2.0 percent of its patient days from managed 



and Medicaid). 

Seasons Palliative Care of Florida, Inc. (CON #10063): The applicant 

is projecting 5.0 percent of its patient days from managed 



and Medicaid), with the remaining 0.5 percent as self-pay/charity. 

United Hospice of Florida, Inc. (CON #10064): The applicant is 

projecting 1.5 percent of its patient days from managed care/commercial 

insurance payers with 97.5 percent of patient days expected to come 

from fixed price government payer sources (Medicare and Medicaid). 

VITAS Healthcare Corporation of Florida (CON #10065): The 

applicant is projecting 2.0 percent of its patient days from commercial 

insurance payers with 97.0 percent of patient days expected to come 

from fixed price government payer sources (Medicare and Medicaid). 

ALL Projects: With the large majority of patient care being provided 

from fixed-price government payer sources, this project is not likely to 

have any discernable positive impact on price-based competition to 

promote cost-effectiveness. As providers offer new or enhanced services 

to patients and families as a means to compete on quality measures, 

cost-effectiveness would be impacted since the new or enhanced services 

would be offered despite the large percentage of fixed-priced government 

payers. In other words, the potential exists for new or enhanced services 

to be provided for the same federal and state dollars. 

Conclusion for all projects: The applicant‟s project is not likely to 

result in price-based competition. 

122


f. Are the proposed costs and methods of construction reasonable? Do 

they comply with statutory and rule requirements? 

ss. 408.035(1)(h), Florida Statutes and Ch. 59A-3 or 59A-4, Florida 

Administrative Code. 

There are no inpatient construction facility costs or methods associated 

with the proposals. 

g. Does the applicant have a history of providing health services to 

Medicaid patients and the medically indigent? Does the applicant 

propose to provide health services to Medicaid patients and the 

medically indigent? ss. 408.035(1)(i), Florida Statutes. 

Compassionate Care Hospice of Florida, Inc. (CON #10061) states 

that it has a history of providing health services to Medicaid patients and 

the medically indigent. According to the applicant, in 2009, its programs 

collectively provided 23,459 Medicaid days representing 3.5 percent of 

total patient days and 17,300 days to self-pay and uncollectible patients, 

representing 2.6 percent of total days. 

Schedule 7A shows Medicaid is projected at five percent of year one and 

4.7 percent of year two patient days. The applicant projects $145,188 for 

charity/self-pay (uncompensated) care in year one, and $102,810 for 

charity care year two. Self-pay (uncompensated) care will account for 5.1 

percent of total patient days for year one and 1.9 percent of total patient 

days for year two (860 patient days and 613 patient days, respectively). 


HealthCare of Central Florida (CON #10062) states that in fiscal year 

2008, approximately 55 percent of the parent‟s (Odyssey HealthCare, 

Inc.‟s) non-Medicare net revenue was Medicaid and approximately 9.5 

percent of non-Medicare services was provided to indigent/charity 

patients. The applicant stresses that it conditions that it will provide 

care to all eligible patients without regard to their ability to pay. As 

stated previously, hospice programs are required by federal and state law 

to provide hospice services to everyone requesting them regardless of 

their ability to pay and therefore the Agency would not place conditions 

on a program to provide legally required services. 

123


Schedule 7A shows Medicaid is projected at three percent of year one 

and year two patient days. The applicant projects $27,823 for 

charity/self-pay care in year one, and $78,101 in year two. According to 

the schedule notes, charity care is reflected in the self-pay column and is 

forecasted at 2.0 percent of patient days for both year one and year two 

(123 patient days and 342 patient days, respectively). 

Seasons Palliative Care of Florida, Inc. (CON #10063) indicates that 

for the 12-month period ending October 2009, 1.9 percent of Season‟s 

hospice patients were Medicaid patients and 1.7 percent were nonfunded. 

Schedule 7A shows Medicaid is projected at four percent of year one and 

year two patient days. The applicant projects $0.00 for charity/self-pay 

care in year one, and $0.00 for charity care year two. However, the 

schedule estimates charity/other payers at $66,900 in year one and 

$143,600 for charity/other payers year two. According to the schedule‟s 

notes, charity care has been recorded as “Other Payers”. According to 

the schedule notes, charity care is reflected in the self-pay column and is 

forecasted at 0.5 percent of patient days for both year one and year two 


United Hospice of Florida, Inc. (CON #10064) indicates that the 

parent, United Health Services, Inc., provided over 10 percent of its 

patient days to Medicaid and indigent care over the three year period 

ending October 31, 2009. According to the applicant, the parent‟s 

Medicaid as percent of total patient days has ranged from as high as 10.0 

percent (2008) to as low as 8.6 percent (2009). Likewise, the parent is 

stated to have had an indigent rate as high as 1.2 percent (2007) to as 

low as 0.4 percent (2009). 

Schedule 7A shows Medicaid is projected at five percent of year one and 

year two patient days. The applicant projects $13,803 for charity care in 

year one, and $54,450 for year two. For both year one and two, the 

applicant forecasts 1.0 percent of patient days to charity care (99 patient 

days and 339 patient days, respectively). 

VITAS Healthcare Corporation of Florida (CON #10065) states that 

“year after year” VITAS provides 1.0 percent or more of revenues in 

charity care and that for fiscal year 2008, this amount exceeded $9.1 

Million. 

Schedule 7A shows Medicaid is projected at 4.7 percent of year one and 

five percent of year two patient days. The applicant projects $82,286 for 

charity care in year one, and $37,422 for charity care year two. The 

124


schedule further forecasts 6.9 percent of patient days for year one and 

1.0 percent of patient days for year two to be for charity patients (519 

patient days and 217 patient days, respectively). 

F. SUMMARY 

In Volume 35, Number 39 of the Florida Administrative Weekly, dated 

October 2, 2009, the Agency for Health Care Administration published a 

need for one hospice program in Hospice Service Area 4A (Baker, Clay, 

Duval, Nassau, and St. Johns Counties) for the January 2011 Hospice 

Planning Horizon. 

All five co-batched applicants propose the establishment of a new 

hospice program in Hospice Service Area 4A, consisting of Baker, Clay, 

Duval, Nassau, and St. Johns Counties. 

Compassionate Care Hospice of Florida, Inc. (CON #10061): The 

proposed total project cost is $227,616 with year one operating costs of 

$2,609,608 and year two costs of $4,236,244. 

Compassionate Care proposes a nine general conditions list with eight 

specific conditions. 


HealthCare of Central Florida (CON #10062): The proposed total 

project cost is $666,972 with year one operating costs of $1,678,931 and 

year two costs of $2,650,443. 

Odyssey proposes 26 conditions. 

Seasons Palliative Care of Florida, Inc. (CON #10063): The proposed 

total project cost is $658,585 with year one operating costs of 


Seasons proposes 20 conditions. 

United Hospice of Florida, Inc. (CON #10064): The proposed total 

project cost is $251,233 with year one operating costs of $1,975,427 and 

year two costs of $5,415,021. 

United proposes one general condition and 10 specific conditions. 

125


VITAS Healthcare Corporation of Florida (CON #10065): The 

proposed total project cost is $338,353 with year one operating costs of 


VITAS proposes one general condition and three primary conditions that 

are each, in turn, bulleted. 

Need/Access: 

Each co-batched applicant is responding to published need for an 

additional hospice program for the January 2011 Hospice Planning 

Horizon and each applicant discusses populations it believes to be 

experiencing unmet need. 

Compassionate Care Hospice of Florida, Inc. (CON #10061) states 

need and access in the context of the following: all ages in all diagnostic 

groups lack hospice access; non-cancer patients age 65 and older lack 

hospice access and geographic and rural challenges in the area overall 

negatively impact hospice care there. The applicant reports a statewide 

hospice penetration for non-cancer patients age 65 or older greater than 

like penetration in hospice service area and offers this as support of need 

for this population group. 

This applicant states that it sent an extensive community assessment 

questionnaire to 242 area providers (hospitals, nursing homes, assisted 

living facilities, end-stage renal disease centers, adult day care and adult 

family care centers). The applicant reports about a four percent response 

rate and that the primary feedback was as follows: no specific unmet 

need was identified, there was need for support services to staff in 

nursing homes after the loss of a long-term resident, unclear causes were 

leading to patients needing IV pain medication, and the applicant was 

welcomed into the local hospice market. The applicant emphasizes that 

according to its survey and all related assessment efforts regarding this 

project, no one responder identified a specific programmatic need. 

Compassionate Care had the fewest letters of support of any of cobatched 

applicant and none by any of the non-health care constituency 

groups the applicant states to be in need of a new/additional hospice 

program in the area. 


HealthCare of Central Florida (CON #10062) states not only the 

Agency-defined need but also states that there are “special and not 

normal” circumstances to warrant a new hospice program in the area. 

126


The applicant states that utilization rates in the area show consistent 

unmet need when compared to statewide averages for cancer patients 

aged 65 years and older; non-cancer patients aged 65 years and older 

and non-cancer patients under age 65. 

Odyssey presents a Hospice Service Area 4A profile, with demographic 

data including major causes of death, three-year age adjusted mortality 

data, county death data and limitation of existing hospice providers in 

the area. Second, the applicant presents a discussion of the rationale 

behind the project, with an explanation of the applicant‟s quality and 

experience. This second point is highlighted by what the applicant 

references as its CareBeyond Program - specialized hospice protocols 

unique to specific diseases including cancer, COPD, congestive heart 

failure and dementia. Third, the applicant presents a quantitative need 

argument and a market forecast. Odyssey discusses need in terms of the 

Agency‟s need projection, Agency‟s need projection modified to include 

the service area‟s higher provision compared to the state average of 

service to cancer patients under age 65 and historical growth rates. 

Seasons Palliative Care of Florida, Inc. (CON #10063) reported senior 

executive staff of Seasons visited the local area on two occasions and 

spent several days assessing the hospice need. The applicant 

concentrated its need determination in the second largest population 

area in the hospice service area – Clay County. Seasons finds the 

hospice population with greatest unmet need to be cancer patients age 

65 and older and non-cancer patients age 65 and older and uses 

statistical data to reach this conclusion. However, this applicant does 

not offer a particular homeless, minority (African American) or rural 

focus as experiencing particular unmet hospice need and is second only 

to Compassionate Care (CON #10061) in having the fewest letters of local 

support to identify need. 

United Hospice of Florida, Inc. (CON #10064) identified the following 

four populations as experiencing hospice under service: minorities 

(African Americans); the homeless; non-cancer patients (of all ages but 

particularly the elderly ages 65 and older) and rural residents 

(particularly in Baker County and to some extent rural Nassau County). 

The applicant supports its conclusions that these groups are in greatest 

hospice need in several ways. The applicant provides published articles 

that nationwide, minorities (the African American population in 

particular) lack adequate hospice care and local data that in 2008, local 

hospitals were discharging African Americans to local hospices at a 

disproportionately lower rate compared to like discharges among all 

other hospice patients. United provides a detailed explanation of its 

outreach efforts and has been successful in doing so in other venues 

127


(such as in Atlanta Georgia) and names specific local African American 

groups it intends to reach. However, the applicant did not have support 

letters from any of these groups. 

United provides a good description of the service area‟s homeless 

population and letters of support from five homeless organizations 

including the Emergency Services and Homeless Coalition of 

Jacksonville, Inc., The Medical Home for Homeless Children Project, the 

I.M. Sulzbacher Center for the Homeless, Family Promise of Jacksonville 

and Presbyterian Social Ministries, Inc. 

With regard to rural concerns, United Hospice is the only co-batched 

applicant to reference that Baker County is within the St. Johns River 

Rural Health Network and is a designated Health Professional Shortage 

Area and Medically Underserved Area as declared by the Shortage 

Designation Branch, Bureau of Health Professions, Health Resources 

and Services Administration, US Department of Health and Human 

Services. There are support letters from Baker County to support the 

project and the applicant states it is well suited to reach rural areas 

based on its stated experience in other similar rural venues in other 

states in which United operates hospice programs (Georgia, North 

Carolina and South Carolina). As for terminally ill non-cancer patients, 

the applicant reports that for the 12-month period ending October 31, 

2009, 73.3 percent of all admissions to the 25 United Hospice programs 

across the southeast region in which it operates were non-cancer 

diagnoses and as high as 87.5 percent in some programs. According to 

United its CareBeyond Program, in which disease-specific hospice care is 

applied to applicable patients, depending on the particular diagnosis 

would be a hallmark to serve this population. 

As part of its in-depth marketing field survey and analysis efforts, the 

applicant states that United Hospice conducted a town hall meeting at 

the Crown Plaza Hotel in Jacksonville (Duval County), on December 15, 

2009 and that this was published by a widely circulated local newspaper 

(The Florida Times-Union) for three consecutive days. United has the 

second most letters of commitment to enter into appropriate 

arrangements for inpatient hospice beds, should the project be approved, 

with these being in local hospitals and skilled nursing facilities. 

128


VITAS Healthcare Corporation of Florida (CON #10065) utilized 

Medicare Hospice Standard Analytical File 2007 (issued by the Centers 

for Medicare and Medicaid Services) and meetings/interviews by VITAS 

staff with local leaders, to reach the following service area hospice unmet 

need conclusions: African-American patients, non-cancer patients 65 

years of age and older and rural Baker County. 

VITAS had the greatest number of support letters by local/regional and 

state African-American/Black oriented organizations (such as the 

Jacksonville Urban League). The applicant also discussed causes of 

death in the hospice service area in years 2006 through 2008 and states 

that it will develop programs for patients with heart disease, Alzheimer‟s 

disease, HIV/AIDS and pulmonary conditions, offering specialized 

protocols for each diagnosis. VITAS also indicated that in many cases 

patients age 65 and older with a non-cancer diagnosis are already in 

nursing homes when hospice services commence and that VITAS has 

already worked with nursing homes in Florida to address this 

circumstance. VITAS has the most letters of commitment to enter into 

appropriate arrangements for inpatient hospice beds. All are with area 

skilled nursing facilities. 

A support letter from a stated board member of Jacksonville‟s Agape 

Community Health Center (the only support letter for any co-batched 

applicant from a federally qualified health center) also expressed 

awareness of hospice need and isolation in the Baker County area. 

There was also similar support through a letter from the Baker County 

Medical Services, Inc. 

The Agency‟s need methodology that resulted in published need for a new 

program in Hospice Service Area 4A showed the projected number of 

admissions minus the current number of admissions for the January 

2011 Hospice Planning Horizon as 925. Co-batched applicant Seasons 

Palliative Care of Florida, Inc. (CON #10063) proposed the greatest 

admission totals by year two of operations, followed by United Hospice of 

Florida, Inc. (CON #10064), Compassionate Care Hospice of Florida, Inc. 

(CON #10061), VITAS Healthcare Corporation of Florida (CON #10065) 

and Odyssey Healthcare of Collier County, Inc. (CON #10062): 

Total Projected Admissions By Applicant 

for Years One and Two 

CON # Applicant Year One Year Two Both Years 

10061 Compassionate Care 275 415 690 

10062 Odyssey 155 271 426 

10063 Seasons 402 615 1,017 

10064 United Hospice 222 528 750 

10065 VITAS 162 297 459 

Source: CON Application #’s 10061-10065. 

129

Quality of Care: 


Each co-batched applicant offered evidence of its ability to provide 

quality care. 

Compassionate Care conditioned approval to become accredited by the 

Community Health Accreditation Program (CHAP) within 24 months of its 

initial licensure. 

Odyssey conditioned approval to become accredited by the Joint 

Commission and the National Institute for Jewish Hospice by the end of 

its second year of operation. 

Seasons proposes to condition approval to Joint Commission 

accreditation stating that “within the first two years, conforming to the 

eligibility criteria for accreditation, begin the preparatory activities for 

(Joint Commission) accreditation”. 

United Hospice conditioned approval on the provision that it will seek 

and obtain CHAP accreditation upon certification. 

VITAS does not propose to seek private organization accreditation. 

Regardless, Section 408.043 Florida Statutes (4) states that 

“Accreditation by any private organization may not be a requirement for 

the issuance or maintenance of a certificate of need under ss. 408.031- 

408.45.” 

Financial Feasibility/Availability of Funds: 

Compassionate Care Hospice of Florida, Inc. (CON #10061): Without 

results from operations, which were not available for Agency review, an 

analysis of the short and long-term strength of the applicant could not be 

made. However, funding for this project should be available as needed 

the project appears to be financially feasible. 


HealthCare of Central Florida (CON #10062): Funding for this project 

should be available as needed the project appears to be financially 

feasible. 

130


Seasons Palliative Care of Florida, Inc. (CON #10063): Without 

results from operations, which were not available for Agency review, an 

analysis of the short and long-term strength of the applicant could not be 

made. However, funding for this project should be available as needed 

the project appears to be financially feasible. 

United Hospice of Florida, Inc. (CON #10064): Funding for this 

project should be available as needed. The project appears to be 

financially feasible. 

VITAS Healthcare Corporation of Florida (CON #10065): Funding for 

this project should be available as needed the project appears to be 

financially feasible. 

Medicaid/Charity Care: 

CON 

Year One 

Medicaid 

Patient 

Days 


Projected Medicaid and Charity Care Patient Days 

Year One 

Indigent/ 

Self-Pay 

Patient Days 

Year One and Year Two 

131 

Year One 

Total 

Patient 

Days 

Year Two 

Medicaid 

Patient 

Days 

Year Two 

Indigent/ 

Self-Pay 

Patient Days 

Year Two 

Total 

Patient 

Days 

10061 837 860 16,847 1,494 613 31,622 

10062 184 123 6,138 514 342 17,123 

10063 658 493 16,457 1,382 1,037 34,554 

10064 494 99 9,884 1,689 339 33,849 

10065 356 519 7,574 1,083 217 21,661 

Note: Obtained from applicant’s responses to Rule 59C-1.035(1) (i) Florida Administrative 

Code. 

Compassionate Care Hospice of Florida, Inc. (CON 10061): Schedule 

7A shows Medicaid is projected at five percent of year one and 4.7 

percent of year two patient days. The applicant projects $145,188 for 

charity/self-pay (uncompensated) care in year one, and $102,810 for 

charity care year two. Self-pay (uncompensated) care will account for 5.1 

percent of total patient days for year one and 1.9 percent of total patient 

days for year two (860 patient days and 613 patient days, respectively). 


HealthCare of Central Florida (CON #10062): Schedule 7A shows 

Medicaid is projected at three percent of year one and year two patient 

days. The applicant projects $27,823 for charity/self-pay care in year 

one, and $78,101 for charity care year two. According to the schedule 

notes, charity care is reflected in the self-pay column and is forecasted at 

2.0 percent of patient days for both year one and year two (123 patient 

days and 342 patient days, respectively).


Seasons Palliative Care of Florida, Inc. (CON #10063): Schedule 7A 

shows Medicaid is projected at four percent of year one and year two 

patient days. The applicant projects $0.00 for charity/self-pay care in 

year one, and $0.00 for charity care year two. However, the schedule 

estimates charity/other payers at $66,900 in year one and $143,600 for 

charity/other payers year two. According to the schedule‟s notes, charity 

care, which is forecasted to be provided to patients who can‟t pay and 

don‟t‟ qualify for Medicare or Medicaid or don‟t have a third party 

insurance plan which covers hospice services, has been recorded as 

“Other Payers”. Again, according to the schedule notes charity care is 

reflected in the self-pay column and is forecasted at 0.5 percent of 

patient days for both year one and year two (82 patient days and 173 

patient days, respectively). 

United Hospice of Florida, Inc. (CON #10064): Schedule 7A shows 

Medicaid is projected at five percent of year one and year two patient 

days. The applicant projects $13,803 for charity care in year one, and 

$54,450 for charity care year two. For both year one and two, the 

applicant forecasts 1.0 percent of patient days to charity care (99 patient 

days and 339 patient days, respectively). 

VITAS Healthcare Corporation of Florida (CON #10065): Schedule 7A 

shows Medicaid is projected at 4.7 percent of year one and five percent of 

year two patient days. The applicant projects $13,803 for charity care in 

year one, and $54,450 for charity care year two. For both year one and 

two, the applicant forecasts 1.0 percent of patient days to charity care 


G. RECOMMENDATION 

Approve CON #10065 for the establishment of a new hospice program in 


St. John‟s Counties. The proposed total project cost is $338,353 for 

equipment, project development costs and start-up costs. 

CONDITIONS: 

The intent of VITAS Healthcare Corporation is to provide high quality, 

cost-effective and coordinated services for its patients/families and the 

community-at-large. The applicant will make a meaningful contribution 

to the defined underserved areas of African-American persons and those 

persons with non-cancer illnesses in need of hospice care. This will be 

accomplished through its proven experience and programming, 

successful operating model and assured via the conditions proposed by 

132


the applicant. VITAS Healthcare Corporation commits to the following 

core service, non-core service and operational/programmatic conditions 

identified below and commits to meet all of the requested reporting 

requirements and time frames as defined in Chapter 59C-1.013 and 59C- 

1.021, Florida Administrative Code. 

1. Percent of a particular population subgroup to be served. 

• The first population subgroup is defined as hospice patients in 

need of continuous care: VITAS Healthcare Corporation will 

provide at least three percent of its total patient days to 

continuous care by the end of year two. This will be measured 

via a signed declaratory statement by VITAS Healthcare 

Corporation which may be supported via review of patient day 

reports by type and month produced by VITAS Healthcare 

Corporation. 

• The second population subgroup is defined as hospice patients 

with diagnosis other than cancer. The applicant will guarantee 

that at least 65 percent of patients admitted have non-cancer 

diagnoses. This will be measured via a signed declaratory 

statement by VITAS Healthcare Corporation which may be 

supported via review of admission reports by patient diagnosis 

produced by VITAS Healthcare Corporation 

2. Special Programs: VHCF has conditioned the application on the 







These measures will be recorded in VITAS‟ proprietary 









quality care. 

133


• Death Attendance: VITAS Healthcare Corporation will attend at 

least 90 percent of all deaths to ensure patients do not die 

alone. This will be measured via a signed declaratory statement 

by VITAS which may be supported via review of patient medical 

records. 

• Patient Family Satisfaction: VITAS Healthcare Corporation will 

achieve an overall patient satisfaction score of 90 percent or 

above on patient's family evaluation of care while under the care 

of VITAS. This is determined by a mail-in survey sent by VITAS 

to the patient's family and measured by recording all scores. 

• Discipline Specific Satisfaction: VITAS Healthcare Corporation 

will achieve an overall registered nurse satisfaction score of 90 

percent or above on patient's family satisfaction with the VITAS 

nurse while under the care of VITAS. This is determined by a 

mail-in survey sent by VITAS to the patient's family and 

measured by recording all scores. 










3. Other Conditions: VITAS Healthcare Corporation has conditioned 

its application on the provision it will meet or exceed the following 

operational and programmatic indicators: 














• VITAS Healthcare Corporation will admit all eligible patients 

without regard to their ability to pay. 

134














workers. 


















at Jacksonville to fund an endowed teaching chair, 

scholarships, and the Northeast Florida Initiative for Nursing 










Healthcare Corporation identifying not-for-profit organizations 

in need of funding. The charitable contribution condition will 

be measured via a signed declaratory statement by VITAS and 


135


VITAS and United Way of Northeast Florida describing the 

donation process is found behind TAB 11. 






which is predominantly the underserved African American 






Deny CON #‟s 10061, 10062, 10063 and 10064. 

136

AUTHORIZATION FOR AGENCY ACTION 


Authorized representatives of the Agency for Health Care Administration 

adopted the recommendation contained herein and released the State Agency 

Action Report. 

DATE: 

James B. McLemore 

Health Services and Facilities Consultant Supervisor 

Certificate of Need 

Jeffrey N. Gregg 

Chief, Bureau of Health Facility Regulation 

137

state agency action report - Agency for Health Care Administration

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