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STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
KENDALL HEALTHCARE GROUP, LTD. d/ b/ a
KENDALL REGIONAL MEDICAL CENTER,
Petitioner,
V.
THE PUBLIC HEALTH TRUST OF MIAMI-DADECOUNTY, FLORIDA, d/ b/ a JACKSON HOSPITALWEST and STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION,
Respondents.
VARIETY CHILDREN' S HOSPITAL d/b/ a NICKLAUSCHILDREN' S HOSPITAL,
Petitioner,
V.
THE PUBLIC HEALTH TRUST OF MIAMI-DADECOUNTY, FLORIDA d/ b/ a JACKSON HOSPITAL
WEST and STATE OF FLORIDA, AGENCY FORHEALTH CARE ADMINISTRATION,
Respondents.
7
AH0AlkGEPCY C L E R K
2018 APR 2b P 2: 10
CASE NO. 16- 0112CON
AHCA NO. 2015013287
RENDITION NO.: AHCA- - aa3S- FOF- CON
CASE NO. 16- 0113CON
AHCA NO. 2015013290
Filed April 26, 2018 3:57 PM Division of Administrative Hearings
CGH HOSPITAL, LTD. d/b/a CORAL GABLES HOSPITAL; TENET HIALEAH HEALTHSYSTEM, INC. d/b/a HIALEAH HOSPITAL; and LIFEMARK HOSPITALS, INC. d/b/a PALMETTO GENERAL HOSPITAL,
Petitioners,
v.
THE PUBLIC HEALTH TRUST OF MIAMI-DADE COUNTY, FLORIDA d/b/a JACKSON HOSPITAL WEST and STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
Respondents.
----------------------------------~/ EAST FLORIDA-DMC, INC.,
Petitioner,
v.
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,
Respondent,
and
THE PUBLIC HEALTH TRUST OF MIAMI-DADE COUNTY, FLORIDA d/b/a JACKSON HOSPITAL WEST; CGH HOSPITAL, LTD. d/b/a CORAL GABLES HOSPITAL; TENET HIALEAH HEALTHSYSTEM, INC. d/b/a HIALEAH HOSPITAL; LIFEMARK HOSPITALS, INC. d/b/a PALMETTO GENERAL HOSPITAL; and VARIETY CHILDREN'S HOSPITAL d/b/a NICKLAUS CHILDREN'S HOSPITAL,
Intervenors. ____________________________________ /
2
CASE NO. 16-0114CON AHCA NO. 2015013292
CASE NO. 16-0115CON AHCA NO. 2016000043
FINAL ORDER
These cases were referred to the Division of Administrative Hearings (DOAH) where
they were consolidated and the assigned Administrative Law Judge (ALI), Robert S. Cohen,
conducted a formal administrative hearing. At issue in this proceeding is whether, on balance,
Certificate of Need ("CON") application number 10395 by the Public Health Trust of Miami-
Dade County, Florida d/b/a Jackson West Hospital ("JW") to build a 1 00-bed acute care hospital
in Miami-Dade County, Florida, AHCA District 11, and/or CON application number 10394 by
East Florida-DMC, Inc. ("DMC") to build an 80-bed acute care hospital in Miami-Dade County,
Florida, satisfy the applicable criteria and should be approved. The Recommended Order
entered on March 16, 201 7 is attached to this final order and incorporated herein by reference,
except where noted infra.
RULINGS ON EXCEPTIONS
JW, Tenet Hialeah Healthsystem, Inc. d/b/a Hialeah Hospital ("Tenet") and Variety
Children's Hospital d/b/a Nicklaus Children's Hospital ("NCH") all filed exceptions to the
Recommended Order, JW filed responses to Tenet and NCH's exceptions, Tenet filed a response
to JW's exceptions, and DMC and Kendall Healthcare Group, Ltd. d/b/a Kendall Regional
Medical Center ("KMRC") filed joint responses to JW's exceptions, Tenet's exceptions, and
NCH's exceptions.
In determining how to rule upon the parties' exceptions and whether to adopt the ALI's
Recommended Order in whole or in part, the Agency for Health Care Administration ("Agency"
or "AHCA") must follow section 120.57( 1 )([), Florida Statutes, which provides in pertinent part:
The agency may adopt the recommended order as the final order of the agency. The agency in its final order may reject or modify the conclusions of law over which it has substantive jurisdiction and interpretation of administrative rules over which it has substantive jurisdiction. When rejecting or modifying such
3
conclusion of law or interpretation of administrative rule, the agency must state with particularity its reasons for rejecting or modifying such conclusion of law or interpretation of administrative rule and must make a finding that its substituted conclusion of law or interpretation of administrative rule is as or more reasonable than that which was rejected or modified. Rejection or modification of conclusions of law may not form the basis for rejection or modification of findings of fact. The agency may not reject or modify the findings of fact unless the agency first determines from a review of the entire record, and states with particularity in the order, that the findings of fact were not based upon competent substantial evidence or that the proceedings on which the findings were based did not comply with essential requirements oflaw ....
§ 120.57(1 )(f), Fla. Stat. Additionally, "[t]he final order shall include an explicit ruling on each
exception, but an agency need not rule on an exception that does not clearly identify the disputed
portion of the recommended order by page number or paragraph, that does not identify the legal
basis for the exception, or that does not include appropriate and specific citations to the record."
§ 120.57(l)(k), Fla. Stat. In accordance with these legal standards, the Agency makes the
following rulings on the parties' exceptions:
JW's Exceptions
Before ruling on the specific exceptions, the Agency notes that JW raises potential
constitutional issues with the proceeding itself in several of its exceptions. Since there is no
express authority given to the Agency by section 120.57(1), Florida Statutes, to address and rule
on constitutional issues in administrative proceedings, the Agency will not address those
arguments in the rulings on JW's exceptions infra. See also Gulf Pines Memorial Park, Inc. v.
Oakland Memorial Park, Inc., 361 So. 2d 695 (Fla. 1978).
In Exception 1, JW takes exception to Paragraphs 13, 14, 15, 23, 29, 34, 40, 42, 45, 46,
47, 50, 51, 52, 64, 66, 68, 72, 96, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111,
133,163,166,170,181,183,184,187, 188,206,207,208,209,210,211,213,215,216and217
of the Recommended Order, arguing that the proceedings on which the findings of fact and
4
conclusions of law in these paragraphs are based did not comply with the essential requirements
of law because the ALJ improperly considered factors that are not part of the statutory review
criteria of a CON application for a general hospital. Specifically, JW alleges that these
paragraphs deal with the existing providers and applicants' quality of care, the applicants'
availability of resources to complete the proposals and the short and long tenn financial
feasibility of the proposals. The argument JW puts forth in Exception 1 is undermined by the
fact that JW clearly put these factors, including its financial viability, at issue by listing them as
reasons justifying the "need" for the health care facility being proposed (§ 408.035(1)(a), Fla.
Stat.) in its CON application. See JW Exhibit 2, p. 11. Thus, the ALJ correctly considered them
under the criterion of need, and did not depart from the essential requirements of law by doing
so. Additionally, the findings of fact in Paragraphs 13, 14, 15, 23, 29, 34, 40, 42, 45, 46, 47, 50,
51, 52, 64, 66, 68, 72, 96,100,101,102,103,104, 105,106,107, 108,109, 110, Ill, 133,163,
166, 170, 181, 183, 184, 187 and 188 of the Recommended are based on competent, substantial
record evidence. See Transcript, Volume 2, Pages 191, 240-243, 251-252 and 302-304;
Transcript, Volume 3, Pages 446, 503 and 504-505; Transcript, Volume 4, Pages 569 and 578-
579; Transcript, Volume 6, Page 979; Transcript, Volume II, Pages 1802 and 1865; Transcript,
Volume 12, Pages 1929-1930 and 1964-1966; Transcript Volume 13, Pages 2079, 2092 and
2107; Transcript, Volume 14, Pages 2254-2255,2256-2257,2281,2299-2300,2303,2307-2310,
2316-2320 and 2323; Transcript, Volume 15, Pages 2460-2461, 2472-2477, 2484-2485, 2492-
2493, 2495-2496 and 2505; Transcript, Volume 18, Pages 2853-2857, 2858-2867, 2871-2872,
2874-2875 and 2897; Transcript, Volume 21, Pages 3344-3345, 3378-3379, 3384-3387, 3395-
3396, 3438-3444 and 3447-3448; Transcript, Volume 23, Pages 3651-3652 and 3685-3686;
Transcript, Volume 25, Pages 3923-3945; Transcript, Volume 26, Page 4066; Transcript,
5
Volume 28. Pages 4346-4347 and 4356-4372; Transcript, Volume 30, Pages 4636-4649;
Transcript, Volume 33, Pages 4927-4973; DMC Exhibits 1, 22, 24, 27, 161, 162, 163, 164 and
167; JW Exhibit 2; NCH Exhibits 2, 28, 41, 42 and 43; and Tenet Exhibits 15 and 19. Thus, the
Agency cannot reject or modify them. See§ 120.57(1)(/), Fla. Stat.; Heifetz v. Department of
Business Regulation, 475 So. 2d 1277, 1281 (Fla. 1st DCA 1985) (holding that an agency "may
not reject the hearing officer's finding [of fact] unless there is no competent, substantial evidence
from which the finding could reasonably be inferred"). Furthermore, the Agency finds that,
while it has substantive jurisdiction over the conclusions of law in Paragraphs 206, 207, 208,
209, 210, 211, 213, 215 and 216 of the Recommended Order because it is the state agency in
charge of administering Florida's CON law, it cannot substitute conclusions of law that are as or
more reasonable than those of the ALJ. Thus, the Agency denies Exception I as it pertains to
these paragraphs. Lastly, in regard to Paragraph 217 of the Recommended Order, the Agency
disagrees with the ALI's conclusion of law in the paragraph, but not for the reasons put forth by
JW in its exception. Instead, the Agency finds that Paragraph 217 of the Recommended Order
contains conclusions of law that are within the Agency's substantive jurisdiction because it is the
state agency charged with administering Florida's CON program, and that, based upon the
reasoning set forth in the ruling on Tenet's Exception Number One supra, which is hereby
incorporated by reference, it can substitute conclusions of law that are as or more reasonable than
those of the ALJ. Therefore, the Agency grants Exception 1 to the extent that it rejects
Paragraph 217 of the Recommended Order in toto.
InException2,JWtakesexceptiontoParagraphs 145,152,153,154,155,156,157,158,
159, 189, 190, 208 and 209 of the Recommended Order, arguing the proceedings on which the
findings of fact and conclusions of law in these paragraphs are based did not comply with the
6
essential requirements of law because the ALJ improperly considered additional criteria that is
outside the scope of the statutory review criteria for a general hospital CON application.
Specifically, JW alleges the ALI improperly considered payor mix projections and utilization
projections, and erroneously interpreted the requirements of section 408.037(2), Florida Statutes,
as it pertains to how a CON applicant should identify its proposed service area. First, the
Agency disagrees with JW's argument that the ALI improperly considered payor mix projections
and utilization projections because these factors were put forth by JW in its CON application as
reasons that justified a finding of "need" for the proposed health care facility, pursuant to section
408.035(l)(a), Florida Statutes. Thus, JW consented to these factors being examined by the ALI
under the category of need. Specifically, JW stated in its application that a new hospital was
needed because "the proposed project will serve a significant portion of patients who historically
have care access problems - the indigent and Medicaid populations," because "Jackson Health
System already serves residents of the defined 8-Zip Code Primary Service Area (PSA) and 4-
Zip Code Secondary Service Area (SSA)," and because "the proposed service area represents a
fragmented medical market capable of supporting its own community hospital without impact to
existing providers." See JW Exhibit 2, p. 11. Second, payor mix projections and utilization
projections may also be properly considered under the statutory review criteria of "[t]he
availability, accessibility, and extent of utilization of existing health care facilities and health
services in the service district of the applicant" (§ 408.035(l)(b), Fla. Stat.), "[t]he extent to
which the proposed services will enhance access to health care for residents of the service
district"(§ 408.035(1)(e), Fla. Stat.), "[t]he extent to which the proposal will foster competition
that promotes quality and cost-effectiveness"(§ 408.035(l)(g), Fla. Stat.), and "[t]he applicant's
past and proposed provision of health care services to Medicaid patients and the medically
7
indigent" (§ 408.035(1 )(i), Fla. Stat.). Thus, JW's argument that payor mix projections and
utilization projections are outside the scope of the CON review criteria for general hospitals is
erroneous. In regard to JW' s argument concerning the ALJ' s interpretation of section
408.037(2), Florida Statutes, as it pertains to how a CON applicant should identify its proposed
service area, the Agency finds that, while Paragraph 159 of the Recommended Order is actually
a conclusion of law within the Agency's substantive jurisdiction because it involves the
interpretation of section 408.037, Florida Statutes, which the Agency is in charge of
implementing, the Agency cannot substitute a conclusion of law that is as or more reasonable
than that of the ALJ. Additionally, the findings of fact in Paragraphs 145, 152, 153, 154, 155,
156, 157, 158, 159, 189 and 190 ofthe Recommended Order are based on competent, substantial
record evidence. See Transcript, Volume 19, Pages 3074-3075, 3078, 3080-3083, 3085-3093;
DMC Exhibits 1, 22 and 24; and JW Exhibit 2. Thus, the Agency is not at liberty to reject or
modify them. See § 120.57(1)(!), Fla. Stat.; Heifetz, 475 So. 2d at 1281. Lastly, the Agency
finds that, while it has substantive jurisdiction over the conclusions of law in Paragraphs 208 and
209 of the Recommended Order because it is the state agency charged with implementing the
regulations of Florida's CON program, it cannot substitute conclusions of law that are as or more
reasonable than those of the ALJ. Therefore, for all the reasons set forth above, the Agency
denies Exception 2.
In Exception 3, JW takes exception to Paragraphs 13, 14, 15, 23, 29, 34, 40, 42, 45, 47,
50, 51, 52, 64, 66, 68, 72, 96, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 133,
163,166,168,170,181,183,184,187, 188,206,207,208,209,210,211,213,216and217of
the Recommended Order, arguing the proceedings on which the findings of fact and conclusions
of law in these paragraphs are based did not comply with the essential requirements of law
8
because the ALl's considered criteria outside the statutory review criteria for a general hospital
CON application. In regard to Paragraphs 13, 14, 15, 23, 29, 34, 40, 42, 45, 47, 50, 51, 52, 64,
66, 68, 72, 96,100,101,102,103,104,105,106,107,108,109,110,111,133,163,166,170,
181, 183, 184, 187, 188, 206, 207, 208, 209, 209, 210, 211, 213 and 216 ofthe Recommended
Order, the Agency denies Exception 3 based on the reasoning set forth in the ruling on JW's
Exception I supra, which is hereby incorporated by reference. In regard to Paragraph 168 of the
Recommended Order, the findings of fact in this paragraph fall under the statutory review
criteria of "[t]he availability, accessibility, and extent of utilization of existing health care
facilities and health services in the service district ofthe applicant"(§ 408.035(l)(b), Fla. Stat.).
Thus, the proceedings on which the findings of fact in these paragraphs are based did not depart
from the essential requirements oflaw. Furthermore, the findings of fact in Paragraph 168 of the
Recommended Order are based on competent, substantial evidence. See Transcript, Volume 15,
Pages 2505-2506. Thus, the Agency cannot disturb them. See § 120.57(1 )(!), Fla. Stat.; Heifetz,
475 So. 2d at 1281. Paragraph 217 of the Recommended Order has already been addressed by
the Agency in the ruling on JW's Exception I supra, which is hereby incorporated by reference.
Therefore, the Agency denies Exception 3.
In Exception 4, JW takes exception to Paragraph 145 of the Recommended Order,
arguing the proceedings on which the findings of fact in this paragraph are based did not comply
with the essential requirements of law because the ALl allowed DMC to use a utilization
projection that did not comply with the requirements of section 408.037(2), Florida Statutes.
Based on the reasoning set forth in the Agency's ruling on Exception 2 supra, which is hereby
incorporated by reference, the Agency denies Exception 4.
9
In Exception 5, JW takes exception to Paragraphs 3, 24, 25, 29, 34, 40, 41, 42, 72, 96,
100,102,103,104,105,106,107,108,109,110,111,133,163,174,175,176,177,178,179,
180, 181, 183, 186, 187, 188, 206, 207, 208, 209, 210, 211, 213, 216 and 217 of the
Recommended Order, arguing the proceedings on which the findings of fact and conclusions of
law are based did not comply with the essential requirements of law because the ALJ
impermissibly considered the financial feasibility of the proposals. The Agency denies
Exception 5 as it pertains to Paragraphs 29, 34, 40, 42, 72, 96, 100, 102, 103, 104, 105, 106, 107,
108, 109, 110, Ill, 133, 163, 181, 183, 187, 188, 206, 207, 208, 209, 210, 211, 213 and 216 of
the Recommended Order based on the reasoning set forth in the Agency's ruling on JW's
Exception 1 supra, which is hereby incorporated by referenced. Paragraph 217 of the
Recommended Order has already been addressed by the Agency in the ruling on JW' s Exception
1 supra, which is hereby incorporated by reference. In regard to Paragraphs 3, 24, 25, 41, 174,
175, I76, I77, I78, I79, 180 and 186 of the Recommended Order, the issues addressed in the
findings of fact in these paragraphs fall under the statutory review criteria of "[t]he availability,
accessibility, and extent of utilization of existing health care facilities and health services in the
service district of the applicant" (§ 408.035( I )(b), Fla. Stat.), "[t]he extent to which the proposed
services will enhance access to health care for residents of the service district" ( § 408.035(1 )(e),
Fla. Stat.), "[t]he extent to which the proposal will foster competition that promotes quality and
cost-effectiveness" (§ 408.035(l)(g), Fla. Stat.), and "[t]he applicant's past and proposed
provision of health care services to Medicaid patients and the medically indigent" (§
408.035(l)(i), Fla. Stat.). Thus, the proceedings on which the findings of fact in these
paragraphs are based did not depart from the essential requirements of law because the ALJ
correctly addressed the issues in these paragraphs under the statutory review criteria.
10
Furthermore, the findings of fact in Paragraphs 3, 24, 25, 41, 174, 175, 176, 177, 178, 179, 180
and 186 of the Recommended Order are based on competent, substantial evidence. See
Transcript, Volume 1, Pages 88-89 and 1 04; Transcript, Volume 2, Pages 240-243 and 246;
Transcript, Volume 18, Pages 2872-2878, 2880-2881 and 2884-2886; Transcript, Volume 21,
Pages 3384-3385 and 3442-3443; Transcript, Volume 23, Pages 3678-3680; Transcript, Volume
27, Pages 4198-4200; DMC Exhibits 1, 24, 27 and 167; and Tenet Exhibit 5. Thus, the Agency
cannot reject or modify them. See § 120.57(1)(1), Fla. Stat.; Heifetz, 475 So. 2d at 1281.
Therefore, for all these reasons, the Agency denies Exception 5.
In Exception 6, JW takes exception to Paragraphs 3, 29, 42, 105, 111, 181, 183, 187, 188,
206, 211, 213 and 216 of the Recommended Order, arguing the proceedings on which the
findings of fact and conclusions of law are based did not comply with the essential requirements
of law because it alleges the ALJ had a bias against JW since it is a tax-funded hospital system.
The Agency denies Exception 6 as it pertains to Paragraphs 29, 42, 105, 111, 181, 183, 187, 188,
206,211,213 and 216 based on the reasoning set forth in the Agency's ruling on JW's Exception
1 supra, which is hereby incorporated by reference. The Agency denies Exception 6 as it
pertains to Paragraph 3 of the Recommended Order based on the reasoning set forth in the
Agency's ruling on JW's Exception 5 supra, which is hereby incorporated by reference.
In Exception 7, JW takes exception to Paragraphs 13, 14, 15, 23, 40, 45, 47, 50, 51, 52,
66, 68 and 71 of the Recommended Order, arguing the proceedings on which the findings of
facts in these paragraphs are based did not comply with the essential requirements of law
because the ALJ impermissibly considered JW's and DMC's ability to provide quality of care
and their history of providing quality of care. The Agency denies Exception 7 as it pertains to
Paragraphs 13, 14, 15, 23, 40, 45, 47, 50, 51, 52,66 and 68 ofthe Recommended Order based on
II
the reasoning set forth in the Agency's ruling on JW's Exception 3 supra, which is hereby
incorporated by reference. In regard to Paragraph 71 of the Recommended Order, JW's
argument fails because the findings of fact in that paragraph do nothing more than provide
background information on an existing provider in District 11. Additionally, the findings of fact
in Paragraph 71 of the Recommended Order are based on competent, substantial record
evidence. See Transcript, Volume 14, Pages 2311-2312. Thus, the Agency cannot disturb them.
See§ 120.57(1)(1), Fla. Stat.; Heifetz, 475 So. 2d at 1281. For these reasons, the Agency denies
Exception 7 as it pertains to Paragraph 71 of the Recommended Order.
In Exception 8, JW takes exception to Paragraphs 64, 68, 99, 101, 133 and 166 of the
Recommended Order, arguing the proceedings on which the findings of fact in these paragraphs
are based did not comply with the essential requirements of law because the ALJ impermissibly
considered the costs and methods of construction of both proposals. The Agency denies
Exception 8 as it pertains to Paragraph 133 of the Recommended Order based on the reasoning
set forth in the Agency's ruling on Exception 1 supra, which is hereby incorporated by reference.
The Agency denies Exception 8 as it pertains to Paragraphs 64, 68, 101 and 166 of the
Recommended Order based on the reasoning set forth in the Agency's ruling on JW's Exception
3 supra, which is hereby incorporated by reference. In regard to Paragraph 99 of the
Recommended Order, JW's argument fails because the findings of fact in this paragraph have
absolutely nothing to do with either applicant's costs and methods of construction. Instead, they
concern hospital use rates. Furthennore, the findings of fact in Paragraph 99 of the
Recommended Order are based on competent, substantial record evidence. See Transcript,
Volume 3, Page 513; Transcript, Volume 8, Page 1303; Transcript, Volume 23, Page 3730;
DMC Exhibit 1; and JW Exhibit 2. Thus, the Agency is not permitted to reject or modify them.
12
See§ 120.57(1){!), Fla. Stat.; Heifetz, 475 So. 2d at 1281. For these reasons, the Agency denies
Exception 8 as it pertains to Paragraph 99 of the Recommended Order.
In Exception 9, JW takes exception to Paragraphs 12, 22, 46, I 02 and 163 of the
Recommended Order, arguing the proceedings on which the findings of fact in these paragraphs
are based did not comply with the essential requirements of law because the ALJ impermissibly
considered the needs of research and educational facilities, which are not part of the statutory
review criteria for general hospital CON applications. The Agency denies Exception 9 as it
pertains to Paragraphs 46 and 163 of the Recommended Order based on the reasoning set forth in
the Agency's ruling on JW's Exception I supra, which is hereby incorporated by reference. The
Agency denies Exception 9 as it pertains to Paragraph 102 of the Recommended Order based on
the reasoning set forth in the ruling on JW' s Exception 3 supra, which is hereby incorporated by
reference. In regard to Paragraphs 12 and 22 of the Recommended Order, JW's argument is
erroneous because the findings of fact in these paragraphs do nothing more than provide
background information on existing providers in District 11. Furthermore, the findings of fact in
these paragraphs are based on competent, substantial record evidence. See Transcript, Volume
14, Pages 2298-2299 and 2306-2307; and Transcript, Volume 21, Pages 3382-3383. Thus, the
Agency is not at liberty to reject or modify them. See§ 120.57(1)(/), Fla. Stat.; Heifetz, 475 So.
2d at 1281. For these reasons, the Agency denies Exception 9 as it pertains to Paragraphs 12 and
22 of the Recommended Order.
In Exception I 0, JW takes exception to Paragraphs 75, 76, 77, 213, 214 and 215 of the
Recommended Order, arguing the findings of fact and conclusions of law in these paragraphs are
a mischaracterization of the Agency's rationale for preliminarily approving JW's CON
application. The Agency denies Exception 10 as it pertains to Paragraphs 213, 214 and 215 of
13
the Recommended Order based on the reasoning set forth in the ruling on JW's Exception 1,
which is hereby incorporated by reference. In regard to Paragraphs 75, 76 and 77 of the
Recommended Order, JW does not allege a valid basis for the Agency to reject or modify the
findings of fact contained within those paragraphs. Furthennore, the findings of fact in
Paragraphs 75, 76 and 77 of the Recommended Order are based on competent, substantial
evidence. See Transcript, Volume 15, Pages 2493-2495; Transcript, Volume 34, Pages 5117,
5122-5123, 5126-5127, 5130-5131, 5134-5135, 5142-5143 and 5146-5147; and AHCA Exhibit
I. Thus, the Agency is prohibited from rejecting or modifying them. See § 120.57(1 )(!), Fla.
Stat.; Heifetz, 475 So. 2d at 1281. For these reasons, the Agency denies Exception 10 as it
pertains to Paragraphs 75, 76 and 77 ofthe Recommended Order.
In Exception 11, JW takes exception to Paragraphs 62, 63, 84, 102, 114, 115, 137, 146,
147, 148, 149, 152, 153, 154, 155, 156, 157, 158, 159, 160, 163, 165, 166, 168, 169, 170, 172
and 210 of the Recommended Order, arguing the ALJ conducted an improper analysis of JW's
service area definition, utilization projection and adverse impact projections. The Agency denies
Exception 11 as it pertains to Paragraphs 102, 163, 166, 170 and 210 of the Recommended Order
based on the reasoning set forth in the Agency's ruling on JW's Exception I supra, which is
hereby incorporated by reference. The Agency denies Exception 11 as it pertains to Paragraphs
152, 153, 154, 155, 156, 157, 158 and 159 based on the reasoning set forth in the Agency's
ruling on JW' s Exception 2 supra, which is hereby incorporated by reference. In regard to
Paragraphs 62, 63, 114, 115, 137, 146, 147, 148, 149, 160, 165, 168, 169 and 172 of the
Recommended Order, the findings of fact in these paragraphs are based on competent,
substantial evidence. See Transcript, Volume 2, Pages 162-164; Transcript, Volume 7, Pages
1194-1195; Transcript, Volume 10, Pages 1595, 1597-1599 and 1629; Transcript, Volume 15,
14
Pages 2450-2451, 2452-2457, 2465-2466. 2486-2488, 2499-2500, 2503-2504 and 2505-2506;
Transcript, Volume 19, Pages 3076-3077, 3080-3083 and 3100; Transcript, Volume 23, Page
3657; DMC Exhibits 1, 22 and 24; and JW Exhibit 2. Thus, the Agency cannot reject or modify
them. See§ 120.57(1)(1), Fla. Stat.; Heifetz, 475 So. 2d at 1281. Therefore, the Agency denies
Exception 11 as it pertains to Paragraphs 62, 63, 114, 115, 137, 146, 147, 148, 149, 159, 160,
165, 168, 169 and 172 of the Recommended Order. Paragraphs 84 and 165 of the
Recommended Order, while labeled as findings of fact, are actually conclusions of law within
the Agency's substantive jurisdiction because they pertain to whether the facts demonstrate the
need for a new hospital in District 11 pursuant to the statutory and rule criteria the Agency is
charged with implementing. The Agency does not agree with the ALI's conclusions of law in
these paragraphs, but not for the reasons JW put forth in Exception 11. 1 Therefore, the Agency
denies Exception 11 as it pertains to Paragraphs 84 and 165 of the Recommended Order.
In Exception 12, JW takes exception to Paragraphs 24, 41, 100, 128, 161, 173, 174, 175,
176, 177, 178, 179, 180 and 181 of the Recommended Order, arguing the findings of fact in
these paragraphs are not based on competent, substantial evidence and are contrary to the plain
language of section 408.035(1 )(g), Florida Statutes, as well as the Agency's policy and prior
DOAH decisions. The Agency denies Exception 12 as it pertains to Paragraphs 100 and 181 of
the Recommended Order based on the reasoning set forth in the Agency's ruling on JW's
Exception 1 supra, which is hereby incorporated by reference. The Agency denies Exception 12
as it pertains to Paragraphs 24, 41, 174, 175, 176, 177, 178, 179 and 180 based on the reasoning
set forth in the Agency's ruling on JW's Exception 5 supra, which is hereby incorporated by
reference. In regard to Paragraphs 128, 161 and 173 of the Recommended Order, none of these
1 The Agency addresses these paragraphs in its rulings on Tenet's Exception Number Two and Exception Number Three infra.
15
paragraphs runs contrary to section 408.035(1 )(g), Florida Statutes, and all are supported by
competent, substantial record evidence. See Transcript, Volume 15, Pages 2450-2452 and 2488;
Transcript, Volume 19, Pages 3035-3038; and DMC Exhibits 1 and 22. Thus, the Agency is
prohibited from rejecting or modifying them. See§ 120.57(1)(!), Fla. Stat.; Heifetz, 475 So. 2d
at 1281. Therefore, the Agency denies Exception 12 as it pertains to Paragraphs 128, 161 and
173 of the Recommended Order.
In Exception 13, JW takes exception to Paragraphs 100, 190 and 191 of the
Recommended Order, arguing the ALJ's conclusions of law in these paragraphs result from an
improper analysis of JW's and DMC's CON application conditions regarding the provision of
care for Medicaid and indigent patients. The Agency denies Exception 13 as it pertains to
Paragraph 100 based on the reasoning set forth in the ruling on JW' s Exception 1 supra, which is
hereby incorporated by reference. The Agency denies Exception 13 as it pertains to Paragraph
190 of the Recommended Order based on the reasoning set forth in the Agency's ruling on JW's
Exception 2 supra, which is hereby incorporated by reference. In regard to Paragraph 191 of the
Recommended Order, that paragraph contains findings of fact, not conclusions of law as JW
alleges, and the findings of fact are based on competent, substantial record evidence. See
Transcript, Volume 12, Pages 1942-1945. Thus, the Agency cannot reject or modify them. See
§ 120.57(1)(1), Fla. Stat.; Heifetz, 475 So. 2d at 1281. Therefore, the Agency denies Exception
13 as it pertains to Paragraph 191 of the Recommended Order.
In Exception 14, JW takes exception to Paragraphs 205 and 213 of the Recommended
Order, arguing the conclusions of law in these paragraphs are unreasonable and ignore the
Agency's discretion to weigh and balance the statutory review criteria. The Agency denies
Exception 14 as it pertains to Paragraph 213 of the Recommended Order based on the reasoning
16
set forth in the Agency's ruling on JW's Exception 1 supra, which is hereby incorporated by
reference. In regard to Paragraph 205 ofthe Recommended Order, the ALl's conclusions oflaw
in that paragraph are based on the ALJ's weighing of the competent, substantial record evidence.
See Transcript, Volume 23, Pages 3682 and 3701. JW is, in essence, improperly asking the
Agency to re-weigh the record evidence to reach conclusions of law more favorable to it, which
the Agency cannot do. See Heifetz, 475 So. 2d at 1281. For this reason, the Agency denies
Exception 14 as it pertains to Paragraph 205 ofthe Recommended Order.
In Exception 15, JW takes exception to Paragraphs 65, 66, 67, 68, 69, 71, 78, 84 and 203
of the Recommended Order, arguing the ALJ impermissibly allowed DMC to amend its CON
application. The Agency denies Exception 15 as it pertains to Paragraphs 66 and 68 of the
Recommended Order based on the reasoning set forth in the Agency's ruling on JW' s Exception
1 supra, which is hereby incorporated by reference. The denies Exception 15 as it pertains to
Paragraph 71 based on the reasoning set forth in the Agency's ruling on JW's Exception 7,
which is hereby incorporated by reference. The Agency denies Exception 15 as it pertains to
Paragraph 84 of the Recommended Order based on the reasoning set forth in the ruling on JW' s
Exception 11 supra, which is hereby incorporated by reference. In regard to Paragraphs 65, 67
and 69 of the Recommended Order, the Agency finds no evidentiary support for JW's allegation
that KRMC impermissibly amended its CON application. Instead, JW is attempting to twist the
competent, substantial record evidence to support its allegation by making unreasonable
inferences from it. These paragraphs make no indication that DMC amended its CON
application. Instead, they reflect one of the assertions of need that DMC made in its CON
application. See DMC Exhibit 1. Therefore, the Agency denies Exception 15 as it pertains to
Paragraphs 65, 67 and 69 of the Recommended Order. In regard to Paragraphs 78 (which
17
contains conclusions of law and not findings of fact, as labeled by the ALJ) and 203 of the
Recommended Order, the Agency does not agree with the ALl's conclusions of law in these
paragraphs, but not for the reasons JW put forth in Exception 15. In regard to Paragraph 78 of
the Recommended Order, the Agency hereby incorporates the reasoning set forth in the ruling on
Tenet's Exception Number Two infra. In regard to Paragraph 203 of the Recommended Order,
the Agency finds that the conclusions of law in that paragraph are within its substantive
jurisdiction because they involve the detennination of need for a new facility pursuant to section
408.035, Florida Statutes; and the Agency can substitute conclusions of law that are as or more
reasonable than those of the ALJ, based on the reasoning set forth in the rulings on Tenet's
Exception Number One and Exception Number Two infra, which are hereby incorporated by
reference. Therefore, the Agency grants Exception 15 as it pertains to Paragraphs 78 and 203 of
the Recommended Order, adopts and incorporates the modifications to Paragraph 78 of the
Recommended Order that it made in ruling on Tenet's Exception Number Two infra, and rejects
Paragraph 203 of the Recommended Order in toto.
In Exception 16, JW takes exception to Paragraphs 73, 85, 93, 112, 113, 118, 119, 120,
121, 122, 123, 126, 127, 128, 132, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145,
147, 159, 162, 164, 165, 166, 167, 168, 170, 189, 190,201,202,203,211,212 and 217 ofthe
Recommended Order, arguing DMC's utilization projections and adverse impact analysis did not
comply with the requirements of section 408.037(2), Florida Statutes. First, the Agency denies
Exception 16 as it pertains to Paragraphs 137, 145, 147, 159, 165, 166, 168, 170, 189, 190 and
211 of the Recommended Order based on the reasoning set forth in its rulings on JW' s
Exceptions 1, 2, 3, 4 and 11 supra, which are hereby incorporated by reference. Second, the
findings offact in Paragraphs 85, 93, 112, 113, 118, 119, 120, 121, 122, 123, 126, 127, 128, 132,
18
134,135,136,138,139,140,141,142,143,144,162, 164and 167oftheRecommendedOrder
are all based on competent, substantial record evidence. See Transcript, Volume 4, Pages 674
and 686; Transcript, Volume 7, Pages 1103 and 1153-1154; Transcript, Volume 11, Pages 1863-
1865; Transcript, Volume 13, Pages 2079 and 2106-21 07; Transcript, Volume 14, Pages 2256-
2257; Transcript, Volume 15, Pages 2459, 2473-2475 and 2496-2504; Transcript, Volume 19,
Pages 3035-3038, 3043-3050, 3064-3067, 3068-3075 and 3098-3099; Transcript, Volume 21,
Pages 3342-3344; AHCA Exhibit I; and DMC Exhibits 1, 22, 24, 161, 162, 163 and 164. Thus,
the Agency is not at liberty to reject or modify them. See § 120.57(1 )(I), Fla. Stat.; Heifetz, 475
So. 2d at 1281. Third, in regard to Paragraphs 73 (which contains conclusions oflaw and not
findings of fact, as labeled by the ALJ), 20 I, 202 and 212 of the Recommended Order, the
Agency does not agree with the ALJ' s conclusions of law in these paragraphs, but not for the
reasons JW put forth in Exception 16. Instead, the Agency will address Paragraph 73 of the
Recommended Order its ruling on Tenet's Exception 1 infra. The Agency has already addressed
Paragraph 203 of the Recommended Order in its ruling on JW's Exception 15 supra, which is
hereby incorporated by reference, and Paragraph 217 of the Recommended Order in its ruling on
JW's Exception 1 supra, which is hereby incorporated by reference. For all these reasons, the
Agency denies Exception 16.
In Exception 17, JW takes exception to Paragraphs 102 and 163 of the Recommended
Order, arguing the findings of fact in these paragraphs are not based on competent, substantial
evidence. Based on the reasoning set forth in the Agency's ruling on JW's Exception I supra,
which is hereby incorporated by reference, along with the fact that JW's argument is not a valid
reason for the Agency to reject findings of fact under section 120.57(1)(1), Florida Statutes, the
Agency hereby denies Exception 17.
19
In Exception 18, JW takes exception to Paragraphs 62, 99, 101 and 168 of the
Recommended Order, arguing the findings of fact in these paragraphs conflict with each other
and therefore must be rejected by the Agency. For the reasons set forth in the Agency's rulings
on JW' s Exceptions 1, 8 and 11 supra, which are hereby incorporated by reference, and also
because JW's argument is not a valid reason for the Agency to reject findings of fact under
section 120.57(1)(1), the Agency hereby denies Exception 18.
In Exception 19, JW takes exception to Paragraphs 50, 62 and 168 of the Recommended
Order, arguing the findings of fact in these paragraphs conflict with each other, are not based on
competent, substantial evidence, and deal with criteria that is not part of the statutory review
criteria for general hospital CON applications. For the reasons set forth in the Agency's rulings
on JW' s Exceptions I, 3 and 11 supra, which are hereby incorporated by reference, along with
the fact that an alleged "conflict" between findings of fact is not a valid reason for the Agency to
reject findings of fact under section 120.57(1 )(!),the Agency hereby denies Exception 19.
In Exception 20, JW takes exception to Paragraphs 50, 62, 64, 65, 99, 101, 166 and 168
of the Recommended Order, arguing the findings of fact in these paragraphs are contradictory
and thus do not comply with the essential requirements of law. Based on the reasoning set forth
in the Agency's rulings on JW's Exceptions 1, 3, 8, 11 and 15 supra, hereby incorporated by
reference, and because an alleged "contradiction" between findings of fact is not a valid reason
for the Agency to reject findings of fact under section 120.57(1 ){!), Florida Statutes, the Agency
hereby denies Exception 20.
In Exception 21, JW takes exception to Paragraphs 58, 78, 79, 80, 81, 112, 114, 115, 116,
148, 164, 170 and 212 of the Recommended Order, arguing: 1) the findings of fact contradict
each other and are not supported by competent, substantial evidence; and 2) the conclusions of
20
law ignore the Agency's discretion to weigh and balance the statutory review criteria for CON
applications. InregardtothefindingsoffactinParagraphs78, 112,114,115,148, 164and I70
of the Recommended Order, the Agency denies Exception 21 based upon the reasoning set forth
in the Agency's rulings on JW's Exceptions I I, 15 and 16 supra, which are hereby incorporated
by reference. In regard to Paragraphs 58, 79, 80, 81 and I I 6 of the Recommended Order, the
findings of fact in these paragraphs are all based on competent, substantial record evidence. See
Transcript, Volume 2, Pages 159- I 60; Transcript, Volume 15, Pages 2435, 2440-2444 and 2457;
DMC Exhibits 1 and 24; and JW Exhibit 2. Thus, the Agency is prohibited from rejecting or
modifying them. See § I20.57(1)(l), Fla. Stat.; Heifetz, 475 So. 2d at 1281. Therefore, the
Agency denies Exception 2 I as it pertains to Paragraphs 58, 79, 80, 81 and 116 of the
Recommended Order. In regard to Paragraph 212 of the Recommended Order, the Agency does
not agree with the ALJ' s conclusions of law in this paragraph, but not for the reasons JW put
forth in Exception 21.2 Therefore, the Agency denies Exception 21 as it pertains to Paragraph
2 I 2 of the Recommended Order.
In Exception 22, JW takes exception to Paragraphs 84, 1 00, 116, 150 and I 5 I of the
Recommended Order, arguing they are really conclusions of law in which the ALJ improperly
substituted his interpretation of law in place of the Agency's interpretation. In regard to
Paragraphs 84, I 00 and I I 6 of the Recommended Order the Agency denies Exception 22 based
on the reasoning set forth in the Agency's rulings on JW's Exceptions 1, 11 and 21 supra, which
are hereby incorporated by reference. In regard to Paragraphs I 50 and 151 of the Recommended
Order, the Agency disagrees with JW's assertion that these paragraphs contain conclusions of
law. Instead, Paragraphs 150 and 151 of the Recommended Order contain findings of fact that
are supported by competent, substantial evidence. See Transcript, Volume 17, Pages 2828-2833;
2 The Agency addresses this paragraph in its ruling on Tenefs Exception Number Four infra.
21
and DMC Exhibit 24. Thus, the Agency is not at liberty to reject or modify them. See §
120.57(1)(1), Fla. Stat.; Heifetz, 475 So. 2d at 1281. Therefore, the Agency denies Exception 22
as it pertains to Paragraphs 150 and 151 of the Recommended Order.
In Exception 23, JW takes exception to Paragraphs 215 and 216 of the Recommended
Order, arguing the ALJ's conclusion that the fact that DMC's parent company abandoned a prior
CON is not relevant to the consideration of its current CON application is erroneous and should
be rejected by the Agency. The Agency finds that, while it does have jurisdiction over the
conclusions of law in Paragraphs 215 and 216 of the Recommended Order, it cannot substitute
conclusions of law that are as or more reasonable than those of the ALI. Therefore, the Agency
denies Exception 23. However, the Agency notes that the ALJ's conclusions of law in
Paragraphs 215 and 216 of the Recommended Order are limited to the specific facts of this case,
and should not be construed to mean that abandonment of a prior CON could never be relevant
to the consideration of a subsequent CON application.
In Exception 24, JW takes exception to Paragraphs 84, 201, 202, 204, 212 and 217 of the
Recommended Order, arguing the Agency should disregard the conclusions of law in these
paragraphs as unreasonable. In regard to Paragraph 84 of the Recommended Order, the Agency
denies Exception 24 as it pertains to this paragraph based on the reasoning set forth in the
Agency's ruling on Exception 11 supra, which is hereby incorporated by reference. In regard to
Paragraph 204 of the Recommended Order, the Agency finds that, while it does have substantive
jurisdiction over the conclusions of law in Paragraph 204 of the Recommended Order since it is
the state agency in charge of administering Florida's CON program, it cannot substitute
conclusions oflaw that are as or more reasonable than those of the ALJ. Therefore, the Agency
denies Exception 24 as it pertains to Paragraph 204 of the Recommended Order. In regard to
22
Paragraphs 201, 202 and 212 of the Recommended Order, the Agency disagrees with the
conclusions of law in these paragraphs, but not for the reasons JW asserts in Exception 24.3
Therefore, the Agency denies Exception 24 as it pertains to Paragraphs 201, 202 and 212 of the
Recommended Order. Paragraph 217 of the Recommended Order has already been addressed by
the Agency in the ruling on JW's Exception 1 supra, which is hereby incorporated by reference.
Tenet's Exceptions
In Exception Number One, Tenet takes exception to the portion of Paragraph 73 of the
Recommended Order, wherein the ALJ found that "both applications met the statutory criteria
for approval." Tenet argues the finding of fact is not supported by any competent, substantial
evidence. First, the portion of Paragraph 73 of the Recommended Order that Tenet took
exception to is actually a conclusion of law within the Agency's substantive jurisdiction, not a
finding of fact. Second, based on a survey of cases4 involving hospital CON applications that
were submitted to the Agency after the 2008 changes to the review criteria in section 408.035,
Florida Statutes, the ALJ erred in concluding that both applications met the statutory criteria for
approval because neither application demonstrated the need for a new hospital in District 11.
In Memorial Healthcare Group, Inc. d/b/a Memorial Hospital Jacksonville v. Agency for
Health Care Admin. and Shands Jacksonville Medical Center, Inc., Case No. 12-0429CON
(DOAH Dec. 7, 20 12; AHCA Apr. 10, 2013 ), Memorial Hospital Jacksonville submitted a CON
application for a new 1 00-bed acute care hospital in Duval County, Florida, Subdistrict 4-1. The
evidence in the Memorial Hospital Jacksonville case demonstrated that a new hospital was not
3 The Agency addresses these paragraphs in its rulings on Tenet's Exception Number Three and Exception Number Four, and NCH's Exception 3 infra.
4 The Agency did not discuss the case of South Broward Hospital District d/b/a Memorial Healthcare System v. Agency for Health Care Admin., Case Nos. 15-0129CON and 15-0130CON (DOAH Apr. I, 2016; AHCA May 17, 2016), which was also decided subsequent to the 2008 amendments to section 408.035, Florida Statutes, in its ruling
23
warranted because the service area had several existing providers within a reasonable distance of
the applicant's proposed location (Recommended Order at Pages 6-7 and 9), the proposed
service area was relatively small in population size (Recommended Order at Page 24), there was
underutilization of the existing beds in the service area (Recommended Order at Page 21 ), there
were no major geographic barriers that prevented residents of the proposed service area from
accessing existing services (Recommended Order at Pages 29-32), there were no barriers to
emergency services (Recommended Order at Pages 32-35), and no evidence that Medicaid and
indigent patients from the proposed service area were unable to access existing services
(Recommended Order at Pages 36-39). Thus, the Agency entered a final order denying
Memorial Hospital Jacksonville's CON application.
In Columbia Hospital (Palm Beaches) Limited Partnership d/b/a West Palm Hospital and
Jupiter Medical Center, Inc. d/b/a Jupiter Medical Center v. Florida Regional Medical Center and
Agency for Health Care Admin., Case Nos. 12-0428CON and 12-0496CON (DOAH Apr. 30,
2013; AHCA Jun. 6, 2013), Florida Regional Medical Center submitted a CON application for a
new 80-bed acute care hospital in Palm Beach County, Florida, Subdistrict 9-4. The evidence in
the Columbia Hospital case demonstrated that a new hospital was not warranted because there
was low population growth in the proposed service area (Recommended Order at Page 20), there
was underutilization of the existing acute-care beds in the subdistrict (Recommended Order at
Page 21 ), there would be no increase in geographic or programmatic access to health care
services because the proposed location of the new facility was only a few miles from existing
facilities (Recommended Order at Page 28), and there would be a substantial adverse impact to
existing providers because the applicant's proposed service area completely overlapped that of
on Tenet's Exception Number One because it is not relevant to the case at hand since it involved a CON application for a replacement hospital, which would not result in any new providers being added to a district.
24
the existing providers (Recommended Order at Pages 35-39). Thus, the Agency entered a final
order denying Florida Regional Medical Center's CON application.
In Lee Memorial Health System v. Agency for Health Care Admin., Case Nos. 13-
2508CON and 13-2558CON (DOAH Mar. 28, 2014; AHCA Apr. 24, 2014), Lee Memorial
Health System submitted a CON application for a new 80-bed acute care hospital in Lee County,
Florida, AHCA District 8. The evidence in the Lee Memorial case demonstrated that a new
hospital was not warranted because the proposed service area was relatively small in population
size (Recommended Order at Page 19), there was underutilization of the existing acute care beds
in the district (Recommended Order at Page 26), there would be no increase in geographic or
programmatic access to health care services because the proposed location of the new facility
was only a few miles from existing facilities (Recommended Order at Pages 30-42), and no
enhanced access for Medicaid and indigent patients of the proposed service area (Recommended
Order at Pages 42-44). Thus, the Agency entered a final order denying Lee Memorial Health
System's CON application.
The case at hand is very similar to those of Memorial Hospital Jacksonville, Columbia
Hospital and Lee Memorial. The city of Doral has a relatively small population (Recommended
Order at Paragraph 96). The existing beds in District II are underutilized with an overall
occupancy rate of roughly 53% (See Transcript, Volume 23, Page 3660; Tenet Exhibit 5). And,
there was no competent, substantial record evidence that the "geographic barriers to access"
alleged by both JW and DMC prevented residents of the proposed service area from accessing
existing providers (See,~' Transcript, Volume 17, Pages 2753-2759). In sum, if the Agency
were to grant either applicant a CON, it would be departing from prior Agency precedent without
any rational explanation. Thus, the Agency finds that it has substantive jurisdiction over the
25
conclusion of law in Paragraph 73 of the Recommended Order because it is the state agency in
charge of administering Florida's CON program, and that it can substitute conclusions of law
that are as or more reasonable than those of the ALI. Therefore, the Agency grants Exception
Number One and modifies Paragraph 73 of the Recommended Order as follows:
73. Although 00-thneither of the applications met the statutory criteria for approval, the Agency preliminarily approved JW's CON application and denied DMC's Application.
In Exception Number Two, Tenet takes exception to Paragraphs 78 and 84 of the
Recommended Order, as well as the last sentence of Paragraph 97 of the Recommended Order,
arguing the findings of fact in these paragraphs are not based on competent, substantial evidence
and that the conclusion of there being need for a new hospital "is unfounded and cannot stand."
Paragraphs 78, 84 and 97 of the Recommended Order are a mixture of findings of fact and
conclusions of law regarding the need for a new facility in District 11. As it stated in the
reasoning set forth on Tenet's Exception Number One supra, the Agency finds that the facts of
this case do not demonstrate a need for a new hospital in District 11 in light of the cases of
Memorial Hospital Jacksonville, Columbia Hospital and Lee Memorial, which are prior Agency
precedent and pertinent to this matter. There is no competent, substantial record evidence that
the alleged "geographic barriers to access" prevented residents ofthe proposed service area from
accessing existing providers. See,~' Transcript, Volume 17, Pages 2753-2759. Additionally,
the population size and growth of Doral is not significant enough to justify the need for a new
hospital. See, ~' Transcript, Volume 17, Page 2759. Furthermore, granting DMC's
application in order to decompress KRMC is not warranted because KRMC currently has excess
capacity and is in the process of expanding its facility. See,~' Transcript, Volume 17, Pages
2771-2774. In sum, there is no competent, substantial record evidence to support the ALI's
26
findings that DMC's application should be granted due to geographic barriers to access, Doral's
dense and growing population, and the need to decompress KRMC. Thus, to the extent these
paragraphs contain findings of fact, the Agency finds that the findings of fact are not supported
by competent, substantial record evidence. To the extent these paragraphs contain conclusions
of law concerning the need for a new facility in District 11, the Agency finds that it has
substantive jurisdiction over the conclusions of law in these paragraphs because it is the state
agency in charge of administering Florida's CON program, and that it can substitute conclusions
of law that are as or more reasonable than those of the ALJ. Therefore, the Agency grants
Exception Number Two, rejects Paragraph 84 of the Recommended Order in toto, and modifies
Paragraphs 78, and 97 of the Recommended Order as follows:
78. Generally, applicants are responsible for demonstrating need for new acute care hospitals. DMC did not established that geographic features surrounding Doral create access barriers for the residents of the area. Doral is a densely populated community that is grmving quickly and lacks a readily accessible hospital. KRMC is a grmving tertiary facility that cannot expand to meet its future demands, and DMC will help decompress KRMC's acute care load so it can focus on its tertiary service lines. 97. Although there is not a hospital in Doral itself, there are a number of hospitals nearby. PGH and Palm Springs Hospital are just north of Doral. KRMC is just south of Doral. Hialeah is northeast of Doral. CGH, Westchester General Hospital and NCH are southeast of Doral. JHS and all of the facilities in and around JHS's main campus are east of Doral. Ho'Never, as described in paragraphs 82 84 above, there are perceived, and based upon patient flmv and utilization, actual geographic barriers to many of these facilities.
In Exception Number Three, Tenet takes exception to the ALJ's statement in Paragraph
165 of the Recommended Order that "need has been demonstrated," and the conclusions of law
in Paragraph 201 ofthe Recommended Order. Tenet argues that the record of this case does not
support the ALJ' s ultimate finding or conclusion that need exists. The portion of Paragraph 165
27
of the Recommended Order to which Tenet takes exception is a conclusion of law. The Agency
finds that it is a conclusion of law within the Agency's substantive jurisdiction because it
involves an interpretation of section 408.035, which the Agency is charged with implementing.
Paragraph 201 of the Recommended Order is also a conclusion of law within the Agency's
substantive jurisdiction because it too involves an interpretation of section 408.035, which the
Agency is charged with implementing. Based on the reasoning set forth in the ruling on Tenet's
Exception Number One supra, the Agency finds that it can substitute conclusions of law that are
as or more reasonable than those of the ALJ. Therefore, the Agency grants Exception Number
Three and modifies Paragraphs 165 and 201 ofthe Recommended Order as follows:
165. Tenet's and NHC's objections to the proposals are twofold: there is no need for a hospital, and if DMC or JW is built, it will adversely impact their respective facilities. However, because need has not been demonstrated, it makes no difference that Tenet and NCH have a relatively low market share in the service area, and DMC will not materially impact those market shares, especially when compared with the adverse impact that approval of JW would have. 201. When reviewing the evidence presented, in totality, by the parties at the final hearing, it is evident that there is a cleamo need in acute care District 11 for an acute care hospital to serve the City of Doral and the surrounding area. § 408.035(1 )(a), Fla. Stat. Further, DMC demonstrated that, on balance, it best satisfies the statutory criteria and v1arrants approval of its application over that ofJ\V.
In Exception Number Four, Tenet takes exception to Paragraph 212 of the Recommended
Order, arguing the AL.T' s conclusion that '"nearly every one of the statutory criteria weighs in
favor of the DMC application" is not supported by the record of this case and should be rejected.
The Agency agrees and finds that it has substantive jurisdiction over the conclusion of law in
Paragraph 212 of the Recommended Order because it is the state agency in charge of
administering Florida's CON program, and that it can substitute a conclusion of law that is as or
28
more reasonable than that of the ALJ. Therefore, the Agency grants Exception Number Four and
modifies Paragraph 212 of the Recommended Order as follows:
212. Overall, nearly every onenone of the statutory criteria weighs in favor of the DMC application.
In Exception Number Five, Tenet takes exception to the last sentence of Paragraph 190
and also Paragraph 191 of the Recommended Order, arguing the ALJ failed to recognize "that
there is legal significance to CON conditions." The Agency disagrees with Tenet's argument.
Furthermore, the findings of fact in Paragraphs 190 and 191 of the Recommended Order are
based on competent, substantial evidence. See Transcript, Volume 12, Pages 1942-1945;
Transcript, Volume 15, Pages 2495-2496; and DMC Exhibits 1 and 24. Thus, the Agency is not
allowed to reject or modify them. See § 120.57(1)(1), Fla. Stat.; Heifetz, 475 So. 2d at 1281.
Therefore, the Agency denies Exception Number Five.
NCH's Exceptions
In Exception 1, NCH takes exception to Paragraphs 78, 79, 80, 81, 82, 83 and 97 of the
Recommended Order, arguing the findings of fact in these paragraphs are not based on
competent, substantial evidence. In regard to Paragraphs 78 and 97 of the Recommended Order,
which contain a mixture of findings of fact and conclusions oflaw, the Agency grants Exception
1 based on the reasoning set forth in the ruling on Tenet's Exception Number Two supra, which
is hereby incorporated by reference, and adopts the resulting modifications it made to these
paragraphs in that ruling. In regard to Paragraphs 79, 80, 81, 82 and 83 ofthe Recommended
Order, the Agency denies Exception 1 because these paragraphs contain findings of fact that are
based on competent, substantial record evidence. See Transcript, Volume 15, Pages 2435, 2440-
2444 and 2457; and DMC Exhibits 1 and 24.
29
In Exception 2, NCH takes exception to Paragraph 84 of the Recommended Order,
arguing the findings of fact in this paragraph are not based on competent, substantial evidence.
Paragraph 84 of the Recommended Order is actually a conclusion of law within the Agency's
substantive jurisdiction because it concerns whether an applicant has demonstrated the need for a
new facility pursuant to section 408.035. The Agency finds that it has substantive jurisdiction
over the conclusion of law in Paragraph 84 of the Recommended Order because it is the state
agency in charge of implementing Florida's CON program, and that it can substitute a
conclusion of law that is as or more reasonable than that of the ALJ. Therefore, the Agency
f,Tfants Exception 2 and rejects Paragraph 84 of the Recommended Order in toto.
In Exception 3, NCH takes exception to Paragraphs 201 and 202 of the Recommended
Order, arguing that, contrary to the ALJ' s conclusions of law in these paragraphs, neither JW nor
DMC demonstrated that there was a need for a new hospital in the service area. Based on the
reasoning set forth in the ruling on Tenet's Exception Number One and Exception Number Three
supra, which are hereby incorporated by reference, the Agency agrees with NCH's argument.
Paragraphs 201 and 202 of the Recommended Order are conclusions of law within the Agency's
substantive jurisdiction because it is the state agency in charge of administering Florida's CON
program, and the Agency finds that it can substitute conclusions of law that are as or more
reasonable than those of the ALJ. Therefore, the Agency grants Exception 3, rejects Paragraph
202 in toto, and adopts and incorporates the modifications it made to Paragraph 201 of the
Recommended Order in the ruling on Tenet's Exception Number Three supra.
FINDINGS OF FACT
The Agency hereby adopts the findings of fact set forth in the Recommended Order,
except where noted supra.
30
CONCLUSIONS OF LAW
The Agency hereby adopts the conclusions of law set forth in the Recommended Order,
except where noted supra.
ORDER
Based upon the foregoing, both JW's CON application no. 10395 and DMC's CON
application no. 10394 are hereby denied. The parties shall govern themselves accordingly.
DONE and ORDERED this 2b1J.day of____.A'-.Ljor-'--'rl-=-·/ ___ , 2018, in Tallahassee, Florida.
I
CRETARY TH CARE ADMINISTRATION
NOTICE OF RIGHT TO JUDICIAL REVIEW
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO
A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A
NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY
ALONG WITH THE FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT
COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY
MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW
PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA
APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF
RENDITION OF THE ORDER TO BE REVIEWED.
31
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing Final Order has
been furnished by the method indicated to the persons named below on this ~ ~-f ----'-ztg-+-...... u....:..t-r~/ __ ,, 2o18.
COPIES FURNISHED TO:
Honorable Robert S. Cohen Chief Administrative Law Judge Division of Administrative Hearings (via electronic filing)
Geoffrey D. Smith, Esquire Susan C. Smith, Esquire Corinne T. Porcher, Esquire Smith & Associates 3301 Thomasville Road, Suite 201 Tallahassee, Florida 32303
RICHARD J. SHOOP, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308-5403 (850) 412-3630
(via electronic mail to [email protected], [email protected] and [email protected])
Christopher C. Kokoruda, Esquire Laura E. Wade, Esquire Eugene Shy, Jr., Esquire Assistant County Attorneys Miami-Dade County Attorney 1611 Northwest 12111 Avenue West Wing, Suite 109 Miami, Florida 33136 (via electronic mail to [email protected], [email protected], and [email protected])
32
Stephen A. Ecenia, Esquire R. David Prescott, Esquire Craig D. Miller, Esquire Rutledge Ecenia, P .A. 119 South Monroe Street, Suite 202 Tallahassee, Florida 32301 (via electronic mail to [email protected], [email protected], and [email protected])
Thomas F. Panza, Esquire Paul C. Buckley, Esquire Elizabeth L. Pedersen, Esquire Angelina Gonzalez, Esquire Panza, Maurer & Maynard, P .A. Coastal Tower 2400 East Commercial Boulevard, Suite 905 Fort Lauderdale, Florida 33308 (via electronic mail to [email protected], [email protected], [email protected], and [email protected])
Michael J. Glazer, Esquire Steven M. Hogan, Esquire E. Dylan Rivers, Esquire Ausley McMullen Post Office Box 391 123 South Calhoun Street Tallahassee, Florida 32302 (via electronic mail to [email protected], [email protected], [email protected], and [email protected])
Richard J. Saliba, Esquire Kevin M. Marker, Esquire Assistant General Counsels (via electronic mail to [email protected] and [email protected])
Marisol Fitch Certificate of Need Unit (via electronic mail to [email protected])
Jan Mills Facilities Intake Unit (via electronic mail to [email protected])
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