ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT ...ahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10017.pdf · ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Adventa Hospice Services of Florida, Inc./CON #10016

400 East Bay Street, Suite 406 Jacksonville, Florida 32202 Authorized Representative: Roger A. Cochran, Ph.D. (904) 634-0276

HCR Manor Care Services of Florida II, Inc./CON #10017

333 North Summit Street Toledo, Ohio 43604 Authorized Representative: Mr. Bruce Schroeder (419) 252-5668 Hospice of Lake & Sumter, Inc./CON #10018

2445 Lane Park Road Tavares, Florida 32778 Authorized Representative: Ms. Pat Lehotsky (352) 742-6816 Odyssey Healthcare of Marion County, Inc./CON #10019

717 North Harwood, Suite 1400 Dallas, Texas 75201

Authorized Representative: Mr. R. Dirk Allison

(214) 245-3266

CON Action Numbers: 10016-10022

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VITAS Healthcare Corporation of Florida/CON #10020

999 Ponce De Leon Boulevard, Suite 950 Coral Gables, Florida 33134 Authorized Representative Ms. Patricia Greenberg (305) 444-5007 HPH-Haven Alliance, Inc./CON #10021

12107 Majestic Boulevard Hudson, Florida 34667 Authorized Representative Mr. Rod Taylor (727) 863-7971 Voyager Hospice Care, Inc./CON #10022

118 N. Gadsden Street, Suite 200 Tallahassee, Florida 32301 Authorized Representative Mr. Robert A. Weiss (850) 681-0191

2. Service Area/Subdistrict

District 3, Hospice Service Area 3B, Marion County B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area 3B. However, letters of support were submitted, as discussed below.

Adventa Hospice Services of Florida, Inc. (CON #10016) included 40 letters of support with its application. Many of these letters were form letters signed by area residents, physicians, and other medical professionals. Of the 40 letters, two were letters of support from Palm Garden of Ocala, Administrator, Jennifer Mikula and Life Care Centers of America Southeast Division, Vice President, Robert Sprague on behalf of Life Care Center of Ocala. These letters state that the nursing homes wish to pledge their support to Adventa and their willingness to work with them on an arrangement to provide routine residential and inpatient hospice services. The applicant also received letters of support from

CON Action Number: 10016-10022

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Crystal Home Medical Equipment Inc. and Superior Non-Emergency Transportation Inc. stating their willingness to contract and negotiate for the provision of home medical equipment and transportation services. HCR Manor Care Services of Florida II, Inc. (CON #10017) included 49 letters of support from area residents, physicians, pharmacists, assisted living facilities, nursing homes, and other medical professionals. Many of the supporters state that an additional hospice provider is needed in Marion County to provide choice for residents as well as health care professionals. Other supporters state that competition results in an environment that promotes quality and cost-effectiveness. Eight of the 49 letters of support were from area assisted living facilities and nursing homes. While seven of the eight agreed that an additional hospice provider is needed in Service Area 3B and support the applicant, two stated their willingness to negotiate on contract options for inpatient care, Palm Garden of Ocala, and Marion House Health Care Center. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) submitted 153 letters of support with its application from physicians, area businesses, hospitals, assisted living facilities, volunteers, and community leaders. A letter was also received from Representative Hugh H. Gibson III, Florida House of Representatives, District 42 in support of the applicant. Representative Gibson asserts that as a former Board of Directors Member, he is familiar with the applicant’s commitment to excellence and its highly regarded reputation. He believes that the applicant will enhance the choices available for quality hospice services in Marion County. Three letters of support were from nursing homes (Oakhurst Rehabilitation and Nursing Center, Palm Garden of Ocala, and Marion House Health Care Center) and three were from assisted living facilities (Quiet Oaks, Hawthorne Inn of Ocala, and Superior Residences at Cala Hills). The three letters of support from nursing homes stated that they look forward to Cornerstone providing hospice services to their residents and the three assisted living facilities also stated their willingness to work with the applicant. The applicant received seven letters of support from health care professionals associated with hospitals outside of the service area: six from Florida Hospital Waterman (five case managers and the one from an RN with the home infusion unit) and one from the Senior Vice President & Administrator of The Villages Regional Hospital. Florida Hospital Waterman (Lake County) and The Villages Regional Hospital (Sumter) are located in counties adjoining to southern Marion County. The support letters generally state that having another hospice in the area would benefit the patients, families, referral sources and the community. It is also noted that a few of the supporters express difficulty with the current hospice provider.


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Odyssey Healthcare of Marion County, Inc. (CON #10019) submitted six letters of support with its application. Two letters were from nursing homes (Palm Garden of Ocala and Marion House Health Care Center) and two were from assisted living facilities (The Bridge at Ocala and Summerville at Ocala West). Marion House Health Care Center, The Bridge at Ocala, and two other ALFs, Chambrel at Pinecastle and Summerville at Ocala East also provided memorandums of understanding for contracted services with the applicant. Marion House Health Care Center indicates that it “intends on entering into a mutually agreeable contract …for the provision of routine, general inpatient and respite inpatient services”. The other letters of support were submitted by an area physician and an ALF resident coordinator with The Bridge at Ocala. The support letters state that having another hospice in the area would benefit the patients, families, referral sources and the community. It is also noted that a few of the supporters experienced great difficulty with the current hospice provider regarding admission timeliness and weekend availability. VITAS Healthcare Corporation of Florida (CON #10020) submitted 17 letters of support with its application. Nine of the 17 letters were submitted by Service Area 3B residents and community leaders. Four of the letters of support were submitted by the ALS Association, Miami VA Medical Center, VA Medical Center West Palm Beach and the Florida Department of Veteran Affairs. One letter was submitted by Kindred Hospital Ocala stating its support for VITAS in Marion County. The remaining letters were from area businesses. HPH-Haven Alliance, Inc. (CON #10021) submitted 178 letters of support with its application. The letters of support were from assisted living facilities, community businesses, skilled nursing facilities, physicians, government officials, state agencies, hospitals, and other medical professionals. Congresswoman Ginny Brown-Waite, U.S. House of Representatives, 5th Congressional District Florida, and State Representative Kurt Kelly, Florida House of Representatives, District 24, both submitted letters of support for the applicant. Representative Brown-Waite states that having access to hospice services is an important resource for the residents of the 5th Congressional District. She also states that she will work with and support the applicant when they receive the license to provide hospice care for Marion County. Representative Kelly states that he was impressed with the applicant’s level of commitment, wealth of experience, not-for-profit business model and creativity and innovation in delivering hospice services to the community. Fifteen of the letters of support were from assisted living facilities of which 10 stated their willingness to consider working with the applicant if approved: Azalea Gardens Assisted Living, Clobran Assisted


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Living, Hawthorne Inn of Ocala, Prestige Manor, Prestige Manor II, Solita’s Comfort, Inc., Summerville at Ocala West, Summerville at Ocala East, Superior Residences, and Sure Care Manor. Six of the letters of support were from skilled nursing facilities of which four stated their willingness to work with the applicant “to provide higher levels of care to our patients within our facilities”: Marion House Health Care Center, New Horizons Rehabilitation Center, Oakhurst Rehabilitation & Nursing Center, and Ocala Health and Rehabilitation Center. The other nursing homes were Palm Garden of Ocala and Citrus Health & Rehabilitation Center, which is not in the hospice service area. Four letters were from hospitals all lending their support to the applicant: Seven Rivers Regional Medical Center (not in Service Area 3B), Kindred Hospital Ocala, Ten Broeck Hospital, and Villages Regional Hospital (not in Service Area 3B). Two of the four (Ten Broeck Hospital and Kindred Hospital of Ocala) state their willingness to work with the applicant should Adventa be approved. Voyager HospiceCare, Inc. (CON #10022) submitted six letters of support. Three were from existing Voyager HospiceCare Divisions’ providers and referrers, two were from nursing homes and one was from an independent living retirement community. Palm Garden of Ocala stated a willingness “to negotiate and contract with Voyager for the establishment of inpatient hospice services at our facility” and Ocala Health and Rehabilitation stated it “will consider entering into an agreement to provide inpatient care for Voyager Hospice patients”. Marion Woods provided a letter of support citing admissions delays once hospice benefit has been chosen and residents being persuaded to leave their “home” for care in a hospice house as reasons to encourage the option of an additional choice of hospice. Letters of Opposition The sole hospice provider in Service Area 3B, Hospice of Marion County, represented by John F. Gilroy, III, P.A. submitted a representative sample of community letters of support for Hospice of Marion County and in opposition to all of the co-batched applicants. There were a total of 268 letters submitted. Many of the letters of opposition were of the form letter variety. Hospice of Marion County contends that it succeeds in making quality, cost-efficient hospice services available and accessible to all segments of Marion County and its residents and does not believe that it has left any area of the county, or group of residents, underserved. HMC also states that as a result of substantial efficiencies in operation, and the continuing generous support of the community and its volunteers, as well as strong relationships with local hospitals and other health care facilities, it has been able to offer and provide a comprehensive level of hospice care to all residents.


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C. PROJECT SUMMARY

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 care to the indigent and charity

patients. The applicants’ proposed conditions are as they stated and as

they proposed to report on same. However, many of these conditions are

required hospice services and as such would not require condition

compliance reports. Should a project be approved, the applicant’s proposed

conditions would be reported in the annual condition compliance report as

required by Rule 59C-1.013 (4) Florida Administrative Code. Section

408.606 (5) Florida Statutes states that “The agency may deny a license to

an applicant that fails to meet any condition for the provision of hospice

care or services imposed by the agency on a certificate of need by final

agency action, unless the applicant can demonstrate that good cause exists

for the applicant’s failure to meet such condition”.

Adventa Hospice Services of Florida, Inc. (CON #10016) proposes to establish a new hospice program in Hospice Service Area 3B, Marion County. Adventa, a for-profit corporation, is owned by Adventa Hospice, LLC (AH). Adventa does not currently offer any hospice services in Florida. However, Adventa’s parent company, Amedisys Hospice, LLC, which is in turn, is owned by Amedisys, Inc. does provide licensed and accredited hospice care in 47 separate hospices in 17 states: Alabama, Alaska, Colorado, Georgia, Idaho, Indiana, Kansas, Louisiana, New Hampshire, North Carolina, Oregon, Pennsylvania, Tennessee, Texas, Virginia, West Virginia and Wyoming. The applicant has agreed to condition award of the CON upon providing the following: 1. Special program to assist patients without caregivers living at

home. The director of operations will make an annual report to AHCA as confirmation.

2. Programs and services for the Hispanic community.

• Adventa will designate an outreach coordinator for the Hispanic

Community. The focus will be on increasing hospice access to Hispanic patients and families, providing bereavement care and make written materials available in Spanish. The coordinator will be selected from existing Adventa staff and to the extent possible will be bilingual in Spanish and English.


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• The director of operations will make an annual report to AHCA as confirmation. This report will provide the number of Hispanic patients that were served and the types of services provided, and other Hispanic community outreach activities conducted.

3. Establish bereavement support groups in at least one outlying area

in Marion County. • The director of operations will provide an annual report to

AHCA of bereavement meetings in outlying areas.

4. A quality of life program will be established to offer support therapies to end-of-life patients. • Establish one or more supportive therapy groups that may

include services such as pet therapy, aromatherapy, or other similar therapies by the end of the first full year of operation.

• The director of operations will provide an annual report to AHCA as confirmation.

5. Creation of an internship training program with a Marion County

based nursing training program. • Establish an internship allowing students to accompany clinical

staff or volunteers in the delivery of hospice care for training and educational purposes. The applicant agrees to maintain this training program for at least five years after licensure, if the educational institution is willing.

• To be documented by the provision of an agreement letter to AHCA. However, this would be an annual reporting requirement that would include documentation confirming that the program is offered and the number of participants during the five years, should the CON be approved.

6. Commitment not to solicit donations in Marion County for any

Amedisys affiliated charity or foundation for a period of five years. • The director of operations will provide an annual report to

AHCA as confirmation.


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7. Commitment to educate volunteers about the existence of the

Christen Foundation and the method by which recommendations for assistance can be made by volunteers and staff.

• Consistent with the previous condition (#6 not to solicit in

Marion County for five years), and in an effort to make funds from the Christen Foundation available throughout Marion County, the applicant will commit to educate all volunteers and staff about the existence of the Christen Foundation and the methods by which recommendations for assistance can be made to the Christen Foundation.

• The director of operations will provide an annual report to AHCA as confirmation.

8. Commitment not to seek construction of an inpatient hospice in

Marion County for a period of 10 years following issuance of CON for this hospice.

• Adventa will contract inpatient beds in Marion County with a

local hospital, skilled nursing facility or one of the existing inpatient facilities operated by the sole existing hospice provider in the county.

• The director of operations will provide and annual report to AHCA as confirmation.

The applicant is proposing total project costs to be approximately $285,141 with year one operating costs of $1,370,054 and year two costs of $2,195,053. HCR ManorCare Services of Florida II, Inc. (CON #10017) (Heartland Hospice), a for-profit corporation, proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. HCR ManorCare, through its subsidiary organizations, operates nationally more than 500 long-term care centers, assisted living facilities, outpatient rehabilitation clinics, home health agencies, and hospices (primarily under the trade names Heartland, HCR ManorCare and Arden Courts). Through its operating group Heartland Home Health and Hospice, HCR ManorCare operates over 60 home health agencies in 17 states, and over 100 hospices in 24 states. HCR ManorCare also operates over 300 nursing homes and assisted living facilities in 30 states. In Florida, HCR ManorCare operates 29 nursing homes, 13 assisted living facilities and seven home health agencies. Heartland’s first Florida Hospice program initiated operations in Service Area 4A on September 6, 2007.


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The applicant is proposing total project costs of $364,262 with year one operating cost of $2,313,438 and year two costs of $3,849,326. The applicant has agreed to condition award of the CON upon providing the following: 1. Conduct semi-annual meetings with all contracted hospitals and

long-term care facilities to review quality of service and responsiveness. Heartland Hospice will establish a written policy in 3B to this effect. Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA.

2. Heartland Hospice commits to provide a minimum of one

educational seminar per quarter focusing on end-of-life issues for professionals who work with end-of-life patients (such as physicians, nurses, religious leaders, etc.). Heartland Hospice will commit a minimum of $75,000 over the first two years of operation for this effort. In addition, the applicant will provide a listing of educational materials regarding end-of-life issues at these seminars. Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA.

3. Heartland Hospice commits to create and implement a public

education program about the benefits of hospice care in Marion County. The goal of this program is to raise awareness and understanding of patients and families regarding hospice care as an end-of-life option. Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA.

4. Establish the patient/family “Special Needs fund” of $10,000 for

each of the first five years of operation of the Service Area 3B hospice to be used by the clinical team members to meet unusual and uncovered patient and family needs. Examples include medical transportation, private duty caregivers, housing, burial funds, music/pet therapist and massage/other alternative therapies. Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA.


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5. Heartland commits, for at least the first five years of operation in

Marion County, to a minimum annual budget of $15,000 per year for the provision of special wish funds for hospice patients and families in Service Area 3B. Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA by the hospice.

6. Heartland Hospice commits to contract for 1.0 FTE physician

specializing in palliative care, in addition to the medical director, to offer palliative care consults for patients served by Heartland Hospice as well as to hospitals, nursing homes, and other care settings in the community in the fiscal year following Heartland Hospice reaching an average daily census of at least 100 patients. Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA.

7. Heartland Hospice commits to provide 24-hour, seven days a week,

telephone response directly by Heartland Hospice Staff, not by a contracted answering service or a computerized attendant within the first year of operation. (This does not include situations when a contracted interpretative service is required). Compliance with this condition will be documented by annual submission of a declaratory statement to AHCA.

8. Heartland Hospice commits to implement a volunteer program

within the first two years of operation that focuses on groups who traditionally have not been significantly involved in hospice programs such as teens and ethnic and racial minorities. Compliance with this condition will be documented by the annual provision of a records summary to AHCA based on the records kept routinely by the Heartland Hospice Volunteer Coordinator.

9. Heartland Hospice commits to develop, in year two, a children’s

and family retreat program(s) to serve the residents of Service Area 3B. These programs will augment traditional bereavement services especially for children experiencing grief or loss. Such programs have been implemented in Pennsylvania, Michigan, Missouri, and North Carolina. Compliance with this condition will be documented by an affirmative statement that this program has been developed and the provision of the program description to AHCA.


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10. Heartland Hospice commits to provide up to $10,000 annually for

tuition reimbursement for employees to continue education in hospice or end-of-life care. This includes tuition reimbursement for Heartland Hospice staff to obtain Certified Hospice Palliative Nurse certification, further enhancing the quality of care for hospice residents, as well as supporting staff ability to advance professionally. Compliance with this condition will be documented by an affirmative statement that a tuition reimbursement process is in place. However, an annual report documenting the expenditure and participation would be required should the project be approved.

11. Heartland Hospice commits to provide access to all patients

without regard to ability to pay in its hospice program in Service Area 3B. Heartland Hospice will serve patients covered by Medicare, Medicaid, and other third-party programs as well as self-pay and charity patients. Compliance with this condition will be documented by a declaratory statement provided to AHCA annually indicating that no patients were denied service based on financial status.

12. Heartland Hospice of Marion County commits to address the

specific needs of patients who are under age 65 and included information in clinical training programs to meet this identified community need. Heartland Hospice will ensure that the community is made aware of our acceptance of patients under age 65 through our community outreach and education programs. Compliance with this condition will be documented by annual submission of a declaratory statement of AHCA.

13. Heartland Hospice will provide specialized training for staff

working with individuals with Alzheimer’s disease to enhance the provision of hospice care to such individuals. Compliance with this condition will be documented by annually providing AHCA with a list of training dates to document that the training has taken place.

14. Heartland Hospice commits that a staff member will contact all

new patients within the next business day of admission and then again within seven days to ensure patient/family needs are being met. Heartland Hospice will establish a written policy to this effect. Compliance with this condition will be documented by annual submission of a declaratory statement that the condition has been met.


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15. Heartland Hospice commits that a pain assessment will be

completed on all patients at time of admission. Heartland Hospice will establish a written policy to this effect. This condition will be documented by annual submission of a declaratory statement that the condition has been met.

16. Heartland Hospice commits to provide 24-hour availability of care

coordination and intake of patients including holidays and weekends. Compliance with this condition will be documented by annual submission of a declaratory statement that the condition has been met.

Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone Hospice) proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. Cornerstone is a not-for-profit corporation and has a hospice program in Service Area 3E Lake and Sumter Counties. The proposed total project cost is $200,347 with year one operating costs of $1,871,786 and year two costs of $4,850,517. The applicant agrees to condition award of the CON to the following: 1. Immediately offer extension team hospice services in Marion

County areas contiguous to Cornerstone’s current service areas, Lake and Sumter Counties.

2. All money donated to Cornerstone Hospice from Marion County

residents will be used solely for programs and services within Marion County.

3. The applicant will not hold any major fund-raising events (such as

golf tournaments) within Marion County during the first two years of operation.

4. Money received by Cornerstone in gifts and memorials will be used

for patient care and programs to help better the community of Marion County.

5. Develop at least one community advisory focus group within the

first year of operation.

6. Establish a “Minority Outreach Program” to serve the needs of Marion County’s Hispanic and Black populations in need.


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7. Provide a part-time minority outreach person to serve the needs of the Hispanic community by the end of the first year of operations.

8. Provide a part-time minority outreach person to serve the Black

population by the end of the first year.

9. Extend Cornerstone’s Diversity Council for hospices into Marion County.

10. Form partnerships with Marion County’s indigent and migrant

service organizations.

11. Implement a Spanish-speaking, culturally competent interdisciplinary team.

12. Offer all patient care materials, brochures, forms, and education in

Spanish.

13. Offer classes in medical Spanish for staff who do not speak Spanish.

14. Develop a specialty long-term care team.

15. Offer a volunteer ‘vigil’ team for the long-term care patients.

16. Implement a “Crosswalk” program for joint care planning between

Cornerstone and skilled nursing facilities.

17. Establish Cornerstone’s trademarked and award winning “Tuck-In” program for hospice patients in adult living facilities.

18. Within the first two years of operation, provide a part-time

Medicaid Specialist to assist Marion County patients and families through the intricate Medicaid applications process.

19. Develop an intergenerational, Teen Volunteer Program within the

first two years of operation.

20. Offer “Life Enrichment” services; massive therapy, aroma therapy, art therapy, music therapy and pet therapy for Cornerstone’s patients and families within the first two years of operation.

21. Develop a “Life Review” program.


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22. Promote Cornerstone’s Hospice Veterans program in Marion County.

23. Collaborate with Marion County’s transport services to establish a

service for ventilator dependant patients who want to die at home.

24. Provide palliative chemotherapy and radiation therapy as clinically appropriate to the patient’s terminal diagnosis.

25. Offer Cornerstone’s extended hospice bereavement services to

families for 18 months after death of their love one.

26. Implement a Community Bereavement program to serve people in Marion County with grief issues who have not used hospice. This will include “Grief in the Workplace” and “Grief in the Schools” programs.

27. Offer Cornerstone’s “Sand Tray” therapy program. Sand tray

therapy utilizes large trays of sand along with objects, toys, figures, etc. provided for a person to place in the sand to “tell a story” of how they are feeling that day. The applicant states that this therapy is helpful for children who are not articulate enough to express their feelings of loss and grief.

28. Offer hospice chaplains to conduct memorial services for families

and nursing homes.

29. Develop a Suicide Prevention educational program for the Marion County community.

30. Offer specialized crisis bereavement individual counseling and

groups such as: children, persons dealing with multiple loss issues, persons dealing with traumatic loss, for example: suicide, murder, disaster, etc.

31. Offer EPEC (Education for Physicians on End of Life Care) and

ELNEC (End of Life Nurses Education Consortium) palliative educational programs for physicians and nurses.

32. Develop a program of scholarship assistance for Home Health

Aides who want to go back to school for nursing.

33. Offer a tuition reimbursement program for staff who wish to further their education in a hospice related field of study.


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34. Develop a Preceptor Mentoring Program for newly graduated nurses in hospice work.

35. Provide lap top computers/PDAs to field staff to provide efficient,

readily accessible documentation.

36. Offer a “Refresher Course” for retired nurses who want to do hospice work.

37. Complete comprehensive pain assessments and follow-up on every

patient, every visit.

38. Provide an “extended care fund” for indigent patients with select needs over and above those provided by reimbursement.

39. Develop a Bioethics and Patient Advocacy hospice committee for

Marion County.

40. Extend Lake County’s End of Life Coalition to collaborate with Marion County’s End of Life Coalition.

Odyssey Healthcare of Marion County, Inc. (CON #10019), a for-profit corporation, proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The applicant has two existing Florida hospice programs in Subdistrict 4B, Volusia and Flagler Counties and District 11, Miami-Dade and Monroe Counties. The proposed total project cost is $584,998 with year one operating costs of $1,574,550 and year two costs of $2,998,618. The applicant has agreed to condition award of the CON to the following:

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 to two percent of

patient days. This will be measured via a signed declaration 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.


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4. The applicant will provide 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.

6. The applicant commits to having every patient 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 (PI) 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 availability 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 provided 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 publication of the relevant collateral materials for the provider and patient community.

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

first year of operation. This will be measured via submission of the names and other relevant information of the ethics committee members and the related schedule of meetings to AHCA.

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 ethics committee members and the related schedule of meetings to AHCA.


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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 and staff of the existing provider. In-service training will 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 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 adults 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 formally 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 by the applicant’s inclusion of Dream Foundation information in Odyssey’s collateral materials.

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

Foundation, will make a $40,000 contribution to an appropriate not-for-profit entity in the community to fund education for end-of-life issues. If approved, 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 for

the development efforts of a children’s hospice program in the Marion County community. The children’s program will offer an expanded hospice benefit for patients up to age 21. This program will 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. After one year and as


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the census of pediatric and PIC patients increases, dedicated staff will be increased to constitute a CSFP (Child and Family Support Program) interdisciplinary team. This will be measured via a signed declaratory statement by the applicant.


the development efforts for community bereavement programs in the Marion County 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 Marion County. 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 year one, full-time staff will be employed. This will be measured via a signed declaratory statement by the applicant.

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

Hispanic 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. Bereavement services will include Hispanic children. This will be measured via a signed declaratory statement by the 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 Foundation will establish

a Children’s Bereavement Camp in Florida by the end of the first year of operation, replicating what currently exists in Odyssey’s SkyCamp. This will be measured via a signed declaratory statement by the applicant.

20. The applicant will have a minimum of three Community Education

Representatives staff members, 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


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least three CER staff members are employed at the proposed new 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. Finally, as evidenced by conditions defined above and by Odyssey’s

broad array of proven hospice services, programs and resources discussed in detail throughout this application, the applicant will model the proposed new hospice program as a Comprehensive Hospice Center as defined in The Florida Model of Hospice Care, A Report for Florida Hospices and Palliative Care, Inc., prepared February, 2004 by the Center of Gerontology & Health Care Research, Brown University School of Medicine. This study is presented in Appendix R. Examples of the research/academic endeavors and community advocacy activities beyond Community Hospice Model activities that support the applicant’s comprehensive hospice center condition include: • Providing Odyssey University on-line training and educational

resources to the community, • Participating with and promoting Dream Foundation activities

and fund raising, • Providing $40,000 to the local market to support enhanced

education for end-of-life care, • Providing dedicated staff for children’s hospice initiatives and

for community bereavement activities, • Establishing a Florida Children’s Bereavement Camp, and • Sponsoring and participating in national hospice care

educational activities including but not limited to support of and participation in the National Palliative and Hospice Care Organization, the Symptom Control and Palliative Care Fellowship Program at the University of Texas’s M.D. Anderson Cancer Center, the Palliative Care Fellowship program at the University of Alabama at Birmingham Fellowship through the Greater Birmingham Palliative Care Fellowship Program and the Clergy End-of-Life-Education Program at Baylor University.

This will be measured via a signed declaratory statement by the applicant. As previously stated, proposed conditions that require reports would be reported in the annual condition compliance report as required by Rule 59C-1.013 (4) Florida Administrative Code.


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VITAS Healthcare Corporation of Florida (CON #10020), a for-profit corporation, proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The applicant and its affiliate currently hold certificate of need approved and licensed hospice programs in the following locations: Hospice Service Area 4B (Flagler and Volusia Counties); Hospice Service Area 7A (Brevard County); Hospice Service Area 7B (Orange and Osceola Counties); Hospice Service Area 7C (Seminole County); Hospice Service Area 8B (Collier County), this being CON #9969; Hospice Service Area 9C (Palm Beach County); Hospice Service Area 10 (Broward County) and Hospice Service Area 11 (Miami-Dade and Monroe Counties). The proposed total project cost is $327,188 with total year one operating costs of $1,395,894 and year two costs of $3,653,469. The applicant states that it is willing to condition award of the CON upon the following: Core Service Conditions • 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. • VHCF will admit all eligible patients without regard to their ability to

pay.

Non-Core Service Conditions • Commit to having every patient being assessed by a physician upon

admission to the hospice. • A physician will serve as a member of every care team and provide

patient visits as required. • 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). These measures will be recorded in Vx via a telephone call using the telephone key pad for data entry. At least 60 percent of patients reporting severe pain of seven to 10 will have their pain reduced to five or less within 48 hours of admission. (Which exceeds Florida Statutes 400.60501, which requires a 50 percent reduction in 96 hours of admission.)

• Implement a pet therapy program to begin immediately.


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Operational/Programmatic Conditions • Implement a TeleCare Program to begin immediately. • Establish a Local Ethics Committee to begin upon certification. • Make charitable contribution from VITAS Healthcare Corporation of

Florida (The Applicant) to American Cancer Society in the amount of $50,000 at the time of certification for educating the community on advance directives. This will be measured via a signed declaratory statement by VITAS and evidence of funds transfer.

• Implementation of CarePlanIT, a handheld bedside clinical information system, by the end of the first year of operation.

• Establish a Clinical Pastoral Education program to begin immediately. • VHCF Marion will become accredited by the National Institute for

Jewish Hospice in the provision of hospice services designed to be compatible with the Jewish religious tenets of end-of-life care by the end of its second year of operation.

HPH-Haven Alliance, Inc. (CON #10021) proposes to establish a hospice program in Hospice Service Area 3B, Marion County. Alliance was formed in May 2008, as a not-for-profit corporation. Alliance has two sponsors, Hernando-Pasco Hospice, Inc. and North Central Florida Hospice, Inc. d/b/a Haven Hospice (both are not-for-profit corporations). Collectively, Hernando Pasco Hospice, Inc., and North Central Florida Hospice, Inc. d/b/a Haven Hospice have hospice programs in Florida in Hospice Service Areas 3A (Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Putnam, Suwannee, and Union Counties), 3C (Citrus County), 3D (Hernando County), 4A (Baker, Clay, Duval, Nassau and St. Johns Counties) and 5A (Pasco County). The proposed total project cost is $462,400 with total operating costs of $2,202,200 year one and year two costs of $3,735,924. The applicant states that it is willing to condition award of the CON upon the following: 1. Alliance Hospice will establish and fully staff an office in Ocala,

Marion County, located west of Interstate 75 along the State Road 200 corridor, by July 1, 2009, or within six months of the receipt of a free and clear Certificate of Need for Service Area 3B. Alliance will notify AHCA of its compliance with this condition via its submission of the final cost report required pursuant to Rule 59C-1.013(3) (a), Florida Administrative Code.


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2. By the end of the third year of operation Alliance Hospice will establish one additional office in Belleview, a community located in the southern portion of Marion County. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

3. Alliance Hospice will respond to patient referrals within two hours

of receipt of the referral. Alliance will provide a written summary copy of its referral log including time referrals, which will contain sufficient detail to enable AHCA to assess Alliance’s success in meeting this condition, as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

4. From the initiation of services, Alliance Hospice will employ two FT

professional liaisons and one FT customer service specialist to ensure response times. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

5. In response to an identified community need, from the initiation of

services, Alliance Hospice will establish a separate and distinct hospice interdisciplinary care team to serve its hospice patients residing in skilled nursing and adult congregate living facilities. For Alliance Hospice patients residing in skilled nursing or adult congregate living facilities who have surrogates and immediate family members living outside of the 3B Service Area, Alliance Hospice social workers will contact them on a weekly basis to provide updates, support and resource referral as approved by the patient and allowed for within state and federal regulations. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code, including provision of a written summary copy of its patient/family database including assigned staff, containing sufficient detail to enable AHCA to assess Alliance’s success in meeting this condition.

6. In response to an identified community need, upon initiation of

services, Alliance Hospice will establish and publish hospice admission criteria for cancer patients receiving chemotherapy and chemotherapy treatment protocols for the four major cancer diagnoses (lung, prostate, breast, colon). These two documents will be distributed to the local medical community including oncologists. The hospice admission criteria and chemotherapy


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treatment protocols will clearly articulate Alliance Hospice’s admission criteria for cancer patients receiving chemotherapy and the use of chemotherapeutic agents for lung, prostate, breast and colon cancers to be supported and paid for by Alliance Hospice as a part of the patient and family care plan. Alliance hospice will provide copies of the admission criteria and chemotherapy treatment protocols, as well as a summary report documenting their distribution to the local medical community, as part of its submission to AHCA of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

7. From the initiation of services, Alliance Hospice will establish a

palliative care consultation service specifically focused to oncologists, oncology patients, and other cancer care providers in order to increase access to hospice care by those with cancer currently receiving chemotherapy. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

8. An Alliance Hospice staff member will contact all patients admitted

at home, not in a facility, within 48 hours after admission and then again after seven days to ensure patient/family needs are being met. Alliance will provide a written summary copy of its patient/family contact log including dates of contact, which will contain sufficient detail to enable AHCA to assess Alliance’s success in meeting this condition, as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

9. Alliance Hospice will conduct a pain assessment on all patients at

time of admission. Alliance will provide a quality assessment performance improvement summary report, containing sufficient detail to enable AHCA to assess Alliance’s success in meeting this condition, as part of its submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.

10. After hours phone calls to Alliance Hospice by patients and

families will be answered by hospice staff, not by a contracted answering service or computerized attendant. Alliance will provide a copy of its policies and procedures regarding after hours patient/family contact as part of its submission of the reports required pursuant to Rule 59C-1.013 (4) Florida Administrative Code.


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11. Alliance Hospice will offer palliative massage therapy services, provided by licensed massage therapists with special training in end-of-life care, to every patient. Palliative massage therapists will be employees of Alliance Hospice. Alliance will provide a copy of its policies and procedures governing palliative massage therapy services and its staffing as part of its submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.

12. Alliance Hospice RN case managers, social workers and chaplains

will use laptop computers in the field to collect and input clinical information into the patient database system in order to maximize available clinical information and response to patient/family needs. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.

13. Alliance Hospice will conduct semi-annual meetings with all

contracted hospitals and long-term care facilities to review quality of patient care as well as service and responsiveness to needs of these providers. Alliance will provide a written quality assessment performance improvement summary report, containing sufficient detail to enable AHCA to assess its success in meeting this condition, as part of its submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.

14. In response to an identified community need, Alliance Hospice will

distribute at least 5,000 advance directives/five wishes throughout 3B through educational presentations, community presentations and targeted direct mailings in its first three years of operation in order to respond to the community need, elevate community awareness of advance care planning and to increase the use of advance directives and living wills. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.

15. Alliance Hospice will establish a patient/family “Special Needs

Fund” of $2,500 per interdisciplinary team per year, not less than $10,000 per year, to be used by the clinical team members to meet unusual and uncovered patient and family needs. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.


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16. In response to an identified community need, by the end of the third year of operation, Alliance Hospice will apply for a certificate of need to establish a dedicated licensed hospice inpatient care facility of at least 12 beds in Service Area 3B. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code, as well as by its submission of the appropriate CON.

17. Alliance Hospice will provide an Emergency Pharmaceutical Kit (E-

Kit) to all hospice patients admitted in their home as appropriate and ordered by a hospice physician in order to provide emergent access to palliative medications in the event of a medical crisis by the patient at night or on weekends, when the patient’s access to palliative medications may be limited or not timely. The E-Kit will be provided in accordance with all applicable state and federal dispersing laws and is intended to be responsive to patient and family needs as well as to enhance patient care after regular business hours at night and on weekends. Alliance will provide a copy of its policies and procedures governing use of E-Kits and a summary report of dispensing records as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

18. Alliance Hospice will contract with Hernando Pasco Hospice (HPH)

pharmacy for hospice related drugs, pharmaceuticals and biological in accordance with state and federal dispensing requirements and statutes. HPH’s pharmacy will dispense the hospice related drugs, pharmaceuticals and biological for the Alliance Hospice patients. The dispersing will include home delivery of medications at no cost to Alliance Hospice patients and families in order to improve hospice services and reduce the caregiver burden of the family/caregivers. Alliance will provide a copy of its contract with Hernando Pasco Hospice for hospice-related drugs, biologicals, and pharmaceuticals as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

19. Alliance Hospice will contract for durable medical equipment

(DME)/home medical equipment (HME) from a specialty hospice medical equipment provider who understands and is responsive to the unique needs of hospice patients and families. Alliance will provide a copy of its DME/HME contract as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.


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20. In response to the identified community need, Alliance Hospice will

staff and offer a specialized children’s assistance program (CAP) to provide special grief support and counseling services for children of the hospice families served by Alliance as well as community referrals for children in need. CAP services will include but will not be limited to: home and/or school visits for individual counseling sessions, as well as bereavement risk assessments to identify grief counseling and support needs. CAP will respond to specific referrals for community trauma events in the local schools or communities. The CAP services will also include group counseling and children’s grief camps. Alliance will notify AHCA of its compliance with this condition via submission of the reports required pursuant to Rule 59C-1.013(4) Florida Administrative Code.

21. Alliance Hospice will conduct a face to face bereavement

assessment for each primary care giver in Marion County within two weeks (14 days) after the death of an enrolled Alliance Hospice patient in order to complete a thorough bereavement risk assessment and to provide grief counseling. Alliance will provide copy of its policies and procedures governing bereavement services and a quality assessment performance improvement summary report as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

22. Alliance will offer individual and group grief counseling services to

any resident of Marion County in need of such services regardless of any prior relationship with Alliance Hospice. Alliance will provide a copy of its policies and procedures governing bereavement services and a written summary report, containing sufficient detail to enable AHCA to assess its success in meeting this condition as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

23. Alliance will conduct semiannual memorial services for those

primary caregivers and families served by Alliance as well as any resident of Marion County. Alliance will provide a copy of its policies and procedures governing bereavement services and a written summary report, containing sufficient detail to enable AHCA to assess its success in meeting this condition as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.


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24. Alliance will pursue and achieve Community Health Accreditation Program (CHAP) accreditation within two years of initial operations. Alliance will supply a copy of its CHAP accreditation certificate, dated to enable AHCA to assess its success in meeting this condition, as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

25. At initiation of service, Alliance will become an organizational

member of Florida Hospices and Palliative Care as well as the National Hospice and Palliative Care Organization (NHPCO). Alliance will supply a copy of its membership certificates in Florida Hospices and Palliative Care as well as NHPCO, dated to enable AHCA to assess its success in meeting this condition, as part of its submission of the reports required pursuant to Rule 59C-1.013(4), Florida Administrative Code.

Voyager HospiceCare, Inc. (CON #10022) proposes to establish a hospice program in Hospice Service Area 3B, Marion County. Voyager was founded in 2003 and provides hospice care in 24 locations in three states: Texas, Kansas, and Missouri. Voyager is a for-profit company and operates a home health agency in San Diego, California. The proposed total project cost is $237,558 with total operating costs of $1,139,183 year one and year two costs of $1,878,822. The applicant states that it is willing to condition award of the CON upon the following: 1. The applicant will centrally locate its main office within Marion

County to promote and assure optimal access to residents of the entire county.

2. The applicant will offer after-hours telephone triage and intake

service through a contractual relationship with Hospice of Palm Beach County. This service will be provided in place of a traditional after-hours answering service. While Voyager HospiceCare of Marion County on-call nurses will be available to physically respond to the patient/family calls 24 hours a day as needed, this service will provide nurses available to triage urgent needs over the phone immediately before the local Voyager HospiceCare nurse arrives at the home or facility. Voyager HospiceCare patient’s and families will not be required to leave “a message” with an untrained person – they will receive responsive and qualified support both on the phone and in person – 24 hours a day, seven days a week.


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3. The applicant will initiate, on an ongoing basis, a referral

satisfaction survey to assure its responsiveness to referral sources. Voyager is currently planning a company wide program that will be implemented in all of its locations.

4. The applicant will implement a post-admission survey to be

completed within 48 to 72 hours of admissions. This survey will assure that any issues or concerns identified by the patient, the family, the referral source or the staff is identified and responded to immediately.

5. The applicant will implement a post-bereavement survey to be

submitted after the conclusion of the bereavement period. This survey will assure that any issues/concerns about the services or responsiveness of Voyager HospiceCare of Marion County are identified and corrected as needed.

6. The applicant will contract with an external organization such as

Deyta for the completion of family satisfaction surveys to assure our responsiveness to the needs of the patient and family. Voyager has implemented these ongoing surveys in all of its programs. The internal goal for each program is to be scored at the 95th percentile of hospice programs nationally. Additional information on the current program at Voyager is provided in response to the Statutory Review Criteria, 3a and in Attachment H.

7. The applicant will target communication efforts, out-reach

programs for bereavement support services, and educational information on access and benefits of hospice and palliative care to those that are most influential with the population that are located in the lower socio-economic areas of Marion County and that population that is most likely underserved. These populations within Marion County typically include minority populations and populations that fall within poverty levels or are socio-economically below the state or county averages. These areas of focus will include but not be limited to churches, eldercare organizations, homeless advocates, and other organizations that serve the patients and families that face end-of-life issues. Geographically the target markets will include but not be limited to the following zip codes 32113, 32134, 32617, 32686, 34470, 34475, 34482 and 34488. Additional information on these zip codes is provided in response to Section E.1. Fixed Need Pool.


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8. The applicant will not develop a residential hospice house in Marion County.

9. The applicant will serve all populations while seeking to expand

the penetration of hospice services to the cancer population of all ages through multifaceted approach education and outreach including:

• For at least the first two years of operation, Voyager will provide

a one-day continuing medical education seminar available to all physicians in the county. The seminar will include a nationally recognized and published physician in the area of hospice and palliative care. Continuing medical education (CME) units will be provided. The program will be targeted to developing “top of mind” awareness of the benefits of hospice and palliative care.

• The applicant will offer and promote to the entire population of Marion County that may be grieving the loss of someone access to its support groups whether or not they receive hospice services at Voyager. While serving to provide professional support during the grieving process it also provides an additional approach to communicating the role of hospice in supporting end-of-life care.

10. The applicant will not seek or solicit donations for at least the first

two years of operation. During that period, Voyager will support Hospice of Marion County’s foundation by sharing its materials with Voyager’s patients and families and by encouraging any requests for donations be sent to the Hospice of Marion County Foundation. At the family’s request Voyager would identify another organization in Marion County that serves patients with end-of-life support needs.

11. The applicant will provide extended bereavement services up to 16

months.

12. The applicant will require that all employees of Voyager participate in End of Life Nursing Education Consortium (ELNEC) training. This is a 16-hour training program specifically structured to teach end-of-life care giving skills.


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13. By the end of the second year of operation, all nurse managers and

at least half of the nurses will be nationally certified in hospice and palliative care. Due to the nature of the questions, the certifying board strongly suggests that all people taking the test have at lest two years of hospice nursing experience before applying for certification.

One way to validate expertise is through certification as a nursing specialist. Certification involves a process that validates and evaluates one’s expertise in a specialty area. While licensure assures minimal competency to practice in a field, certification indicates mastery of a defined body of knowledge. The application process involves verification of licensure and any other requirement (some certification programs require a specific amount of work experience in a specialty area). Knowledge of the specialty area is most often validated via testing. After achieving a passing score, the nurse is certified for a period of years (usually three to five years). Renewal of certification after expiration of the initial period may be done by retesting, or by participating in a process such as HPAR (Hospice and Palliative Alternative Recertification) which assigns points for continuing education and other professional activities. As is described in additional detail throughout the application, Voyager focuses on training and competency. Certification is one of the approaches taken to assure the patient and family receives the services and support they need.

14. All staff of Voyager will receive a minimum of 24 hours of

continuing education annually. Voyager has developed extensive targeted continuing education training programs that train all levels of staff and volunteers. The programs differentiate the training needs and expertise of the various levels assuring the information provides the appropriate level of depth and support on an individual level. Additional information on these programs is provided in response to the Statutory Review Criteria, 3a and also in Attachment O.

15. The applicant will implement a pet therapy program in the first

year of operation. A second non-core support program will be implemented in the second year of operation. That program will be selected based on the needs identified in the first year of operation.


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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. 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, Cheslyn Green, analyzed the application in its entirety with consultation from financial analysts, Derron Hillman and Everett Broussard, 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.


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In Volume 34, Number 14 of the Florida Administrative Weekly, dated April 4, 2008 the Agency for Health Care Administration published a need for one hospice program in AHCA Hospice Service Area 3B for the July 2009 Hospice Planning Horizon. Hospice Service Area 3B is currently served by Hospice of Marion County. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 3B, Marion County.

2. Agency Rule Criteria and Preferences a. Rule 59C-1.0355(4)(e) 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.

None of the co-batched applicants clearly demonstrate that any population in the service area has unmet needs. Each applicant is responding to published need for an additional hospice program for the July, 2009 planning horizon. Although none of the applicants receive preference for this criterion, each applicant discussed serving populations they believe to be underserved. Adventa Hospice Services of Florida, Inc. (CON #10016) identified four segments of the population it contends have unmet needs; the homeless, non-Hispanic blacks, Hispanics, and persons without caregivers. The applicant presented research that identified these subgroups as “marginalized” populations. The research presented also examined the reasons why these populations are not utilizing hospice care. The applicant states that one study found that Hispanics and African Americans reported low hospice utilization arose because of a lack of awareness of hospice and because of the prohibitive cost of health care. Further the study showed that Latinos were more likely to report language barriers, while African Americans were more likely to report mistrust of the system. The research concluded that both groups “were highly receptive to end-of-life care that would provide relief for patients and caregivers and emphasize spirituality and family consensus.”1

1 Wendi Born, K. Allen Greiner, Eldonnia Sylvia, James Butler, Jasjit S. Ahluwalia. 2004. Knowledge, Attitudes, and Beliefs about End-of-Life Care among Inner-City African Americans and Latinos. Journal of Palliative Medicine 7:247-256. doi:10.1089/109662104773709369.


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The applicant states that when they combine the epidemiologically predicted deaths of the homeless in Service Area 3B with the estimated deaths for non-Hispanic blacks and Hispanics there could be as many as 510 deaths in 2010 in these groups. They estimate that number to be the minimum number to be expected in 2008 and 2009, its first two years of operation. The applicant states that these groups will be informed about the availability of hospice care by the specific programs they have outlined in the conditions (Schedule C) of the application. HCR Manor Care Services of Florida II, Inc. (CON #10017) (Heartland Hospice) states that through its analysis there are significant unmet needs in hospice Service Area 3B with particular need demonstrated for patients under age 65 and chronically ill patient populations with Alzheimer’s disease. The applicant states rapidly growing numbers of deaths support the demand for greater Alzheimer’s care. Heartland Hospice states it has developed care strategies for Alzheimer’s patients that integrate contemporary therapies such as massage and music therapy with traditional palliative care2. The applicant states that under-service to the younger age groups is identified through the proportionately low numbers of hospice patients in Area 3B compared to the state rate of hospice patients to deaths, or the penetration rate by disease state. The applicant states demographic trends including rapid population growth rates and increasing number of deaths also support the need for greater services to younger residents. The applicant states that while the Hispanic population in 3B is small, their needs are unique. Heartland states it will meet their needs by providing special programs that cater to this population, to include support from our involvement of bilingual staff and translated literature. These programs will include special community education efforts, clinical care protocols, and bereavement services for families in order to increase participation in hospice for groups traditionally under-represented. Heartland states it will pay particular attention to systematic outreach, education, support groups and recruitment of volunteers and staff in the Hispanic community.

2 Appendix J, CON Application #10017, provides information on the Guide to Understanding and Caring for Persons with Alzheimer’s disease, which is a training manual for Heartland staff.


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Heartland Hospice makes a commitment to serve the populations with unmet needs and will ensure all populations; including minorities are educated about the benefits of hospice care through community educational seminars, distribution of multi-lingual educational materials, and direct counseling utilizing trained staff and volunteers.

Hospice of Lake and Sumter, Inc. (CON #10018) (Cornerstone) states that it has identified several areas of need within the terminally ill population of Marion County. These include cancer patients over the age of 65, patients residing in nursing homes and adult living facilities, culturally and color diverse populations (the Black and Hispanic minority communities in Marion County), and indigent populations including the low income migrant population and the “rainbow people”, who are described as people living in trailers and tents in the Ocala National Forest that have dropped out of society and who are increasingly elderly and indigent. The applicant states that cancer is the second leading cause of death in Marion County. According to the applicant, the April 2007 health needs assessment for Marion County, 20 of the 22 zip codes in Marion County have a higher age-adjusted mortality rate than the state of Florida for cancer. The applicant states that 86.82 percent of patients served by Hospice of Marion County in 2007 were over the age of 65; with only 36.2 percent of the patients served by Hospice of Marion County had a diagnosis of cancer.

The applicant has determined that terminally ill residents in long-term care settings in Marion County have unmet needs. Long-term care settings are unique places of residence that can be challenging for hospices to serve. Cornerstone states it provides care for dying people who reside in a facility with the same intensity and quality as home care patients. The applicant states that Hospice of Marion County served 73 nursing home patients on July 1, 2007, or 15 percent of its total census; and on March 18, 2008 it served 68 nursing home patients or 14 percent of its total census. The applicant claims that this decrease in number of nursing home patients served represents a trend in a county whose population growth and residents over the age of 65 exceeds that of the State of Florida.


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Cornerstone states it has a proven track record of serving minority communities. The development of a cultural and language competent staff that is prepared to meet the needs of the terminally ill minority population is not an easy task but; Cornerstone states it has dedicated significant time and resources to accomplish this goal. The applicant states it has found that developing highly specialized individuals and teams that are racially, ethnically and linguistically diverse is a crucial element in providing culturally competent hospice care. Cornerstone states it has organized and implemented a Diversity Council3; members on this council are dedicated to supporting diversity and providing education for hospice staff and the community. The applicant states that the low income migrant population and the uninsured/underinsured in Marion County are currently underserved by hospice. Cornerstone states it provides hospice services regardless of a person’s ability to pay or immigration status. The applicant states it supports the needs of indigent communities in the following ways: programs that are ancillary to core hospice services; offering assistance in addition to standard hospice services such as a food bank, emergency electricity payments and medication payments; all levels of care including crisis 24-hour nursing is available to indigent patients; widespread bereavement services addressing grief and loss issues; promoting preventative health care; extensive volunteer services, including transportation to physicians and clinics for hospice needs; and hospice experienced palliative care physicians who travel to patients homes providing palliative care. Odyssey Healthcare of Marion County, Inc. (CON #10019) states that establishment of a hospice program in 3B will help expand access to hospice services and will introduce non-price competition into the local market, facilitating the improvement and expansion of available hospice services. Odyssey commits to serve populations with unmet needs and to address the special circumstances that exist within the subdistrict. According to the applicant, populations with unmet needs include those patients who are not admitted within 48 hours of referral, cancer patients over the age of 65 and patients inappropriately being moved from their “home” settings to obtain hospice care.

3 Diversity Council Brochure, Appendix XI, CON Application #10018.


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The applicant states that from January 2004 to September 2006 the existing Service Area 3B hospice has experienced significant delays in admitting patients within 48 hours. The applicant provided in Appendix S as documentation of special circumstances, Hospice of Marion County records and depositions of Hospice of Marion County staff. The applicant states that the Hospice of Marion County served only 75.7 percent of cancer deaths over the age of 65, but statewide, Florida hospices served 90.7 percent of cancer deaths over the age of 65. The applicant further contends that this lower level of service to cancer patients over the age of 65 is not a one time occurrence but has been a consistent trend in Marion County. AHCA data indicates that there were 762 Marion County resident deaths for those aged 65 and over and Hospice of Marion served 577 of these patients or 75.72 percent versus the state’s 28,785 resident age 65 and over deaths from cancer and 26,100 or 90.67 percent of these patients who were served by licensed Florida hospices. Odyssey presents a table on page 130, which documents that this is a common trend that has been ongoing since 2002. Odyssey states it will increase awareness in Marion County about the benefits of hospice care for cancer patients through educational materials and will enhance hospice care for cancer patients. Odyssey contends it will teach referral sources how to identify when hospice may be indicated for cancer patients and the supportive care that can be provided, including: pain and symptom management, radiation and/or chemotherapy, and non-pharmacological therapy. Odyssey states it is also extending its “Care Beyond” program to include oncology. Odyssey lists admission within three hours, with a physician order, by and RN or social worker; specialized daily contact; increased team member visits; education regarding what to expect with the disease process; and ongoing support for caregivers as benefits of the Care Beyond program. With regard to patients inappropriately moved from their “home” setting, the applicant obtained interviews with area administrators stating patients and families are not being informed of or offered the option of returning to what had been their home setting (nursing home, assisted living facility) for continuous/ crisis care or other hospice care in addition to the option of receiving that care in the hospice’s own facilities. The applicant contends that these administrators were concerned that the option of hospice care


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being provided in the setting most familiar to the patient and family is not being offered, when the decision to admit the patient to hospice care is made. Odyssey states it would be able to offer all levels of care to area nursing homes and assisted living facilities; in the event that a patient would normally need to be transferred to the hospital to receive care, Odyssey states it would be able to provided continuous care service in the nursing home or assisted living facility foregoing the need to remove the patient from their “home”.

VITAS Healthcare Corporation of Florida (CON #10020) states that it commits to serve populations with unmet hospice needs and will provide enhanced services for Service Area 3B residents. The applicant identified terminally ill patients in need of continuous care, veterans, cancer patients, non-cancer patients, assisted living facility and skilled nursing facility residents as populations within Marion County with unmet needs. VITAS states its commitment to providing continuous care within Marion County. According to the applicant, continuous care staff is specifically identified in its financial model and associated financial schedules. The applicant projects its continuous care patient days in Marion County to be 4.8 to 5.2 percent in years one and two4. The applicant estimates it will only receive reimbursement for an average 16 hours in a given continuous care day. VITAS states that it intends to implement its Choices for Veterans program, which involves collaboration with the Veteran’s Administration, referring physicians, other caregivers and family members, to facilitate VITAS providing support through an interdisciplinary team dedicated to the clinical and psychosocial care of veterans with life-limiting illness. VITAS explains that its staff is trained to explain to veterans that electing to receive hospice services does not affect other benefits, veterans’ pensions or access to other health care. The applicant states that in CY 2007, there were more than 1,600 veteran deaths in Marion County, which was approximately 40 percent of the County’s total. The applicant states there are no existing specialized veterans’ programs in Service Area 3B. The applicant states it will enhance access to hospice care for veterans via the following initiatives:

4 Schedule 5, CON Application #10020.


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• VITAS’ Choices for Veterans program will be offered in Marion County.

• VHCF will designate one of its hospice reps as the liaison for veterans services.

• Once every two months the veterans representative will present hospice services at one of the eight local Veterans of Foreign Wars (VFW) chapters in Marion County.

• Once every two months the veterans representative will present hospice services at one of the three American Legion chapters in Ocala.

• The veterans hospice representative will present hospice services at least once every month at the Ocala Community Based Outpatient Clinic.

• Meet with representatives of the local VA Medical Center in Gainesville, a minimum of every other month to provide supportive materials, offer educational programs and sponsor workshops.

The applicant states the Marion County cancer penetration rates fall short compared to VHCF subdistricts by 7.6 percentage points (82 percent VHCF/ HMC 74.4 percent). The applicant states 2007 cancer admissions numbered 8,696 cancer deaths 10,608 with a cancer penetration rate of 82.0 percent. As opposed to the Hospice of Marion County which had 768 cancer admissions, 1,032 cancer deaths with a cancer penetration rate of 74.4 percent. The applicant states that adding a new provider will create healthy competition and elevate the community’s hospice penetration overall. VITAS states it is committed to serving end-of-life needs for Service Area 3B cancer patients. The applicant has conditioned to donate $50,000 to the local American Cancer Society chapter for purposes of educating the community on advance directives. VITAS states it has been successful in serving the hospice needs of non-cancer patients. Relative to non-cancer patients, the applicant states 67 percent of its admissions are non-cancer patients compared to the statewide average of 62.9 percent. According to the applicant, Hospice of Marion County provided 66 percent of its hospice admissions to non-cancer patients in 2007, yet 37.7 percent of the incremental need published by AHCA is in the non-cancer category. VHCF states it will fill this gap in service and meet the needs of the terminally ill in Subdistrict 3B. The applicant states there are 37 assisted living facilities and skilled nursing facilities with 2,754 licensed beds in Subdistrict 3B and in 2006, Hospice of Marion County had 22.5 percent of its


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patient days in ALFs and SNFs. VHCF asserts its experience in ALFs and SNFs is, on average greater than 52.2 percent; and suggests the lower numbers in Marion County could be a result of underserved patients or alternatively that persons are being encouraged to relocate from their homes (ALF/SNF) to a hospice house. VITAS states it recognizes providing hospice care within the long-term care environment requires additional training and experience in long-term care regulations, survey processes and care planning. Therefore, it has developed a coordinated plan of care system that builds each long-term care resident’s plan of care from the resident’s assessment protocol summary. The applicant also discusses other benefits it would provide to the Service Area 3B community such as its THINK program where caregivers are trained on how to care for persons of varying cultures and religions. The program was developed by VITAS to train employees and volunteer on diversity issues and how to approach individuals of various cultures and faiths such as Hispanic/Latino Americans, African Americans, Jewish Americans and Muslim Americans. HPH Haven Alliance, Inc. (CON #10021) states it is generally familiar with hospice care delivery in Marion County because of the currently operated hospices in adjacent counties, Haven hospice in Levy, Alachua, Putnam Counties contiguous to the west, north, and northeast; Hernando-Pasco Hospice in Citrus County contiguous to the west and southwest. As a result the applicant states it has recurring instances where the arbitrary licensure boundary of the county line creates an adverse patient service or continuity of care concern.

The applicant states it has identified specific conditions that support AHCA’s determination that an additional hospice program is needed in Service Area 3B: terminally ill cancer patients in need of hospice care are currently underserved when compared to the statewide averages of other hospice providers; nursing home and assisted living facility residents in need of hospice care also appear to be underserved when compared to the statewide averages of other hospice providers; there is no licensed hospice inpatient facility within the service area; and hospice patients do not receive more than a token amount of inpatient facility care at the hospital and nursing home based inpatient facilities that are available.


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Alliance states that the existing service provider’s inability to adequately address the service needs of terminally ill cancer patients is reflected in the care seeking patterns of the population. The applicant states that during the 12 months ending June 2007, cancer patients age 65 and older were nearly twice as likely to receive hospital care outside of Marion County as were other patients in this age group (27 percent versus 14 percent). Younger cancer patients in this age group were also more likely to be hospitalized outside Marion County than were non-cancer patients (31 percent versus 23 percent) according to Alliance. Alliance asserts cancer patients leaving the service area for hospital care are also receiving outpatient treatment from oncology physicians located outside Service Area 3B. In order to assure adequate access to hospice care for these patients, Alliance states it is necessary to establish referral relationships with the hospitals and oncology specialist providing therapeutic services to these out-migrating patients. Alliances states it is well positioned to accomplish this task because two of its sponsor hospices have historic commitments to meeting the hospice needs of cancer patients in addition to providing care in the adjacent 3A and 3C Service Areas. The applicant states that hospice utilization data obtained from the annual reports for the year 2007 filed with State of Florida’s Office of Elder Affairs support the view that the existing hospice program may be under-serving ALF and nursing home residents. The applicant states that Hospice of Marion County provided a lower percentage of its total patient days (27 percent) to ALF care and nursing home residents than either Haven Hospice (29 percent) or Hernando-Pasco Hospice (40 percent). Alliance states persons age 65 and older made up 87 percent of the patients served by Hospice of Marion County compared to 85 percent of Hernando-Pasco Hospice’s patients and 77 percent of Haven Hospice’s patients. As a result, the applicant asserts Hospice of Marion County would be expected to serve a percentage of patients residing in assisted living facilities and nursing homes similar to that of Hernando-Pasco and substantially higher than that of Haven Hospice. The applicant plans to establish its initial office west of Ocala. All of the service area’s population centers except Dunnellon and Fort McCoy fall within a 15-mile radius of the proposed location. The applicant also plans to establish a satellite office in the Bellevue area no later than the third year of operations. According to Alliance, approximately 79 percent of the service area’s population (accounting for 76 percent of resident deaths) resides in zip code


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areas within this 15-mile radius. The applicant has conditioned that by the end of the third year of operations, it will apply for CON to establish a freestanding hospice inpatient care center of at least 12 beds in Service Area 3B.

Voyager HospiceCare, Inc. (CON #10022) has identified a number of population categories that have unmet need. Voyager states it is committed to serving these groups and has provided appropriate conditions that will provide evidence of how it will meet the need. The populations identified with unmet need include: Marion County residents that meet hospice criteria; cancer population (all ages); population in need of more responsive service; population in need of being returned to their home rather than to a hospice house; and population in need of improved outreach, education, and access to hospice. The applicant states AHCA’s need formula indicated that hospice penetration among cancer patients both under and over 65 years of age is lower than found on average in the state. Although this statistic does not by itself confirm this is an unmet need specific to cancer in Marion County, it is indicative that there may be a number of cancer patients that could be served by hospice but are not currently. The applicant states it will seek to expand the “top of mind” knowledge of the hospice benefit among cancer providers, patients, their families, eldercare and end-of-life organizations, and the community at large. Voyager asserts these efforts will include but not be limited to providing annual seminars for physicians on hospice, expanding support groups, targeting outreach efforts particularly to geographic areas with populations that are likely to not seek care. The applicant has conditioned to the above. The applicant states there is significant evidence that the existing hospice agency is routinely not able to respond to the hospice referral/patient need on a timely basis. Voyager asserts its commitment to meet this unmet need and respond to the population that needs immediate care, hospice admission, or support services. Voyager has conditioned its application to providing 24-hour a day/seven days a week triage/intake nurse. Voyager states its community assessment identified significant issues associated with admitting a discharged inpatient to a hospice house rather than to their home environment. Voyager has conditioned not to operate a hospice house in Service Area 3B.


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The applicant states it is committed to assisting the patient in returning to their home environment whether that is a nursing home, an assisted living facility, or their personal home. Voyager states that through both on site time in Marion County and through review of the Marion County needs assessment completed in 2007, it has identified the need to improve education, outreach, and access to hospice services to eight specific zip codes in northern Marion County that have a combination of high risk socio-economic factors. Although these are not the only zip code areas that would indicate being underserved, the applicant states that many of the residents are most likely not aware of hospice and the options provided with this benefit or are likely to opt not to request the services due to financial constraints. Voyager asserts its commitment to meet the needs of all residents of Marion County in need of hospice care and is conditioning approval of its application to assuring that it has plans in place to meet the needs of this population by locating the main office centrally in Marion County, implementing outreach programs, and providing ongoing education assistance to the residents and key referral sources that are aware of these pockets of population that may not be seeking hospice support.

(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 cost-efficient alternative.

Adventa Hospice Services of Florida, Inc. (CON #10016) proposes to provide inpatient care thought a contractual arrangement with an existing inpatient hospice, hospital, or nursing home. Adventa Hospice will identify appropriate institutions and will enter a contractual agreement with one of the existing facilities to provide the inpatient component of hospice care. Two nursing homes have indicated their interest in providing inpatient care for Adventa. Adventa is offering the condition not to construct an inpatient hospice for a 10-year period following issuance of the CON. Life Care Centers of America and Palm Garden of Ocala stated in their letters of support that they would be willing to discuss a contract with the applicant to provide inpatient care for its hospice patients.


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HCR Manor Care Services of Florida II, Inc. (CON #10017) (Heartland Hospice) proposes to provide the inpatient care component of its hospice program through contractual arrangements with existing health care facilities, including the acute care hospitals in the service area, and skilled nursing facilities. Letters of intent to contract for inpatient beds are provided by Palm Garden of Ocala Nursing Home, and Marion House Health Care Center, both letters were signed by the facility administrators. The applicant states that building on its experience in establishing relationships with nursing homes and assisted living facilities, it will quickly create mutual partnerships to better serve hospice patients. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone Hospice) states it has a comprehensive program for providing quality of care across a variety of settings. When a patient’s condition results in acute exacerbation of symptoms related to a terminal diagnosis, the patient may be hospitalized, placed in a skilled nursing home setting or cared for in a hospice inpatient home. Inpatient beds in these settings will be available for short-term periods of crisis to control pain or symptoms that are unable to be controlled in the home setting. The applicant states that patients will be admitted with a plan of care to control symptoms and a discharge plan. The applicant states that overtures have been made to all the hospitals in Marion County to explore contracting relationships for hospice patients. Cornerstone states it has also initiated discussions with area nursing homes for inpatient care. The applicant provided letters of support from Service Area 3B assisted living facilities stating they look forward to working with Cornerstone in providing end-of-life care in Marion County5. The applicant states Pat Lehotsky, the President and CEO of Cornerstone, and Alice Privett, the CEO of Hospice of Marion County, have been colleagues at Florida Hospice and Palliative Care for many years and have discussed possibilities for more direct collaboration such as contracting for Cornerstone to place patients in the Marion County hospice houses. The applicant states that upon approval, Cornerstone’s Villages Hospice House will be available for any resident of Marion County who is a hospice patient with skilled needs and wishes to receive

5 Application CON Application #10018, Appendix VII-A; VII-G.


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services there. The applicant states that this will benefit those residents of Marion County who currently have the desire to receive services from The Villages Hospice House but cannot. Odyssey HealthCare of Marion County, Inc. (CON #10019) will use existing licensed hospital and skilled nursing facility beds to serve patients in need of inpatient hospice services. Odyssey states it will contract with acute care providers and skilled nursing facilities in Subdistrict 3B. Robert Mondrone, MPA, NHA Administrator of Marion House Health Care Center indicates in his letter of support intent to enter into a mutually agreeable contract between his SNF and Odyssey for the provision of routine, general inpatient and respite inpatient services. Odyssey also has a letter of support from Palm Garden of Ocala. VITAS Healthcare Corporation of Florida (CON #10020) states that by partnering with hospitals, nursing homes and assisted living communities, to provide hospice care, it will fulfill its goal to expand awareness of and utilization of hospice. The applicant states it will establish inpatient agreements with in the subdistrict upon approval. The applicant did not provide contractual agreements for services from Service Area 3B providers. HPH-Haven Alliance, Inc. (CON #10021) states its two sponsors, Hernando-Pasco and Haven Hospice, have extensive experience in the provision of the inpatient hospice care component of their hospice programs. Alliance states it has received letters from three nursing homes in Marion County indicating a willingness to contract for inpatient hospice care beds, but does not name the facilities. Letters of support show four facilities: Marion House Health Care Center, New Horizon Rehabilitation Center, Oakhurst Rehabilitation & Nursing Center, and Ocala Health and Rehabilitation Center; indicate a willingness to consider entering “into a contract to provide higher levels of care to our patients within our facilities”. The applicant states it will establish all necessary agreements with hospitals and nursing homes prior to initiation of services in 3B. Alliance has conditioned to apply for CON for an inpatient unit in Marion County by the end of the third year of operation. Voyager HospiceCare, Inc. (CON #10022) will contract with existing hospitals and skilled nursing facilities in Marion County to provide inpatient beds. Voyager has letters from Ocala Health and Rehabilitation and Palm Garden of Ocala indicating a willingness to contract for inpatient beds. The applicant states its hospice


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care representatives as well as the Chief Operating Officer met with administrators of skilled nursing homes to provide information about Voyager and to seek their support for the project and future contracting.

(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.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that it does not discriminate based upon a patient’s status as having or not having a primary caregiver at home and that it will work with the patient to devise a plan of care that meets their needs for the safe delivery of hospice care. Adventa states that by the end of year two of operations it will serve a minimum of 15 persons who are in one of the three groups identified, those without a caregiver, those who are homeless, and those with AIDS. In taking care of patients without caregivers, the applicant states that if the person does not have a caregiver then they will educate the patient on identifying someone who could come to assist, such as a family member of friend. If not, the next step would be to determine if there is a family member they could go to. If that is not an option, then Adventa will attempt to help the patient locate a community resource such as a nursing facility placement or ALF placement to support them. The applicant states that it uses the same strategies with the homeless as it does with patients without caregivers. The applicant assesses the patients’ needs as they are evaluated for hospice and certainly as they are admitted and a plan of care to help them is developed. Adventa states that it works with the homeless patient to help them get into a shelter or get into services that they need such as nursing facility placement, through state assistance or whatever. The applicant further states that it has a commitment to serving AIDS patients which is evidenced by one of the disease management plans provided for specific guidance for physicians with AIDS patients6.

6 A copy of the prognostic indicators provided to physicians is provided in Appendix E, CON Application #10016.


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HCR Manor Care Services of Florida II, Inc. (CON #10017) (Heartland Hospice) states that it is committed to serving patients who do not have primary caregivers at home; the homeless; and patients with AIDS, by having a longstanding policy that states the company’s commitment to such patients. When a hospice patient can no longer care for him or herself, the Hospice’s Plan of Care works with the individual to assure that a primary caregiver can be designated. With the relationship among nursing homes and assisted living facilities each person can be placed so that the patient benefits from hospice care. A lack of a home or a primary caregiver will not result in a person foregoing the hospice benefit. The applicant states that in order to ensure continuity of care, the hospice RN will contact the primary care physician to discuss the need to admit to respite, inpatient, or outpatient, and obtain the order7. Heartland Hospice commits to provide hospice services to all, without discrimination: “Heartland Hospice will not discriminate on the basis of ability to

pay, race, ethnic origin, sex, sexual orientation, handicap status, age,

or other category that may classify a person as medically

underserved. The proposed hospice services will be provided to all

hospice appropriate patients based on physician orders and the

hospice plan of care. Hospice services will be available 24 hours per

day/7 days per week.

HCR Manor Care Hospice will admit and treat all persons without

regard to race, color, creed, national origin, ancestry, religion, six,

age, handicap, marital status, or sexual preference. There is no

distinction in the manner of providing palliative care to terminally ill

persons and their families.

Admissions will not be refused nor services discontinued or

diminished due to the inability of the patient/caregiver to pay for

care. Just as all others, patients with a terminal illness and family

needs of personalized care who are not fully covered by Medicare or

Medicaid will be admitted in accordance with NHO criteria.

7Appendix O for a copy of a sample HCR policy and Appendix P for the plan for primary care giving and intake form CON Application #10017.


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A Medical Social Worker will assist patient/family in completing a

financial assessment to determine need. If there is no insurance or

funds, hospice will provide services. The hospice RN will contact the

primary care physician to discuss the need to admit to respite,

inpatient or outpatient and obtain the order.

Medically indigent individuals are defined as persons who do not

qualify for Medicare, Medicaid, Private Insurance, or other identified

healthcare benefits payments program and who do not have the

resources and ability to pay for their care. Medically indigent

persons typically include the working poor and elderly that live out or

near poverty levels of income. As stated before, HCR Manor Care

will not discriminate against the ability to pay for services being

rendered.8” Hospice of Lake and Sumter, Inc. (CON #10018) (Cornerstone Hospice) states its dedication to providing hospice services to people without regard to financial, caregiver, living arrangements, or diagnostic status is established in its non-discrimination policies9. The applicant states it provides care regardless of a person’s ability to pay or the presence of a caregiver and has traditionally accepted dying patients into the program whether or not there is a willing and able caregiver present. The applicant states caregivers are assessed upon a patient’s admission and on a regular basis thereafter to ascertain their knowledge and ability to provide care; hospice volunteers are trained to supplement the caregiver. Cornerstone states when caring for homeless patients, it makes an effort to find suitable housing for them. According to the applicant, contacts have been made with Marion County’s homeless shelter to understand the needs of the homeless within the county. Cornerstone states it has utilized many alternatives including short-term hotel payment for homeless patients. Cornerstone states it does not discriminate against eligible patients by diagnosis and recognizes that the complex care needs of AIDS patients require the hospice interdisciplinary team to communicate with all concerned according to the wishes of the patient. Cornerstone states it collaborates with AIDS service organizations to provide holistic palliative care to dying AIDS patients.

8 A copy of Heartland Hospice patient handbook is included in Appendix Q CON Application #10017. 9 Non-discrimination policies Appendix XXVII-B: Policies CON Application #10018.


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Odyssey HealthCare of Marion County, Inc. (CON #10019) states it provides services to all patients who meet the criteria for admission to hospice which includes patients who do not have a primary care giver at home, the homeless and patients with AIDS. Odyssey non discrimination policy states: ”Odyssey offers palliative care to terminally ill patients and support

to those patients and their families without regard for diagnosis,

gender, sexual orientation, national origin, race, creed, disability,

age, place of residence or ability to pay.”

Odyssey states in the event a patient is impaired with physical problems that can no longer be managed at home, or if a patient is homeless, the nurse evaluates the patient for possible inpatient admission to a hospital or long-term care facility10. The applicant states its teaching materials for HIV assists referral sources to identify patients who may be eligible for hospice service with the diagnosis of HIV disease, to provide aggressive pain and symptom management, psychosocial, spiritual and emotional support for patients and loved ones, and advising on expectations as illness progresses. Odyssey states it is fully prepared to admit patients with HIV/AIDS to its hospice program. VITAS Healthcare Corporation of Florida (CON #10020) states that terminally ill patients with no at home support will receive increased attention from hospice staff. Every effort will be made to develop a caregiver network from among neighbors, nearby relatives and friends, church members and hospice volunteers who will be capable of providing the necessary amount of supervision, assistance and companionship to the patient within the patient’s or caregiver’s home. The applicant states if the patient lives alone and does not have family or friends who live nearby and is able to care for him or herself for the most part, VHCF will assist the patient in developing a network of caregivers to assist the patient or recommend that qualified adult sitter services be obtained should that not pose a financial hardship. In addition, the applicant states it provides patients and family members with cell phones and/or landline phones for 24-hour access and communication to those who may not have one available.

10 Refer to Appendix H, Odyssey Policy and Procedure Manuals Tables of Contents, CON Application #10019.


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If a patient is not able to care for him/herself, has no clear caregiver support, or is homeless, VHCF may recommend placement in an assisted living facility or nursing home in which the hospice program will be able to provide residential care services as if “at home”. With regard to AIDS patients, VHCF states it is aware that Service Area 3B has some level of HIV related deaths and accordingly will institute a level of program to assure terminally-ill individuals with HIV obtain hospice services. In addition to serving HIV/AIDS patients in the United States, VITAS states it is present in Africa fighting the AIDS epidemic by providing hospice care to those infected with the disease. VITAS states it is an active supporter of the Foundation for Hospices in Sub-Saharan Africa which provides financial and in-kind support to hospice providers in Sub-Saharan Africa. VITAS states its commitment to lending its support and expertise has not only brought assistance to a world many miles away, but has also helped the organization to become better educators and trainers. HPH-Haven Alliance, Inc. (CON #10021) states its sponsors (Hernando-Pasco Hospice and Haven Hospice) have a longstanding history of and commitment to exceeding federal and state licensure requirements and to extended care to non-traditional elements of the service area population.

The applicant states that Hernando-Pasco has always accepted patients without caregivers, making use of resources both within the hospice organization and between the hospice and community to enhance support as needed. HPH states it does not specifically identify homeless patients as the patient’s “home” is the point of service most of HPH’s homeless patients are in acute need of assistance and are referred by hospitals or nursing homes. Others remain in their place of residence, even if that is a homeless shelter, and receive care as appropriate, with eventual relocation usually to a nursing home or a licensed inpatient facility. HPH states it created a support group for HIV/AIDS patients in 1987 and out of that effort grew the Pasco AIDS Support Community Organization. HPH asserts it commitment to providing ongoing services to this population. Similar to its Alliance partner, Haven Hospice provides service to everyone who makes inquiry and commits to admit all patients who qualify for hospice care within its licensed service area,


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including homeless persons, persons without primary caregivers, and persons with HIV or AIDS. Haven states it does not keep records directly reflecting homelessness or caregiver status, but these groups are being served in its current operations. Haven Hospice is currently in year three of a five-year rural area demonstration grant project authorized by section 409 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The demonstration is designed to test whether provision of hospice services provided by a demonstration hospice program to Medicare beneficiaries who lack an appropriate caregiver and who reside in rural areas result in wider access, improved hospice services, benefits to the community, and a sustainable pattern of care. The authorizing language allowed for awards to up to three hospices nationwide. The applicant states that Haven Hospice was chosen on the strength of its long history of service to a wide geographic area comprised primarily of rural counties, its strategically located high-quality inpatient facilities within the area, and its management and reporting capabilities. The applicant states that while Marion County is a metropolitan statistical area and thus no part of the county qualifies as “rural,” much of Marion County north of Ocala, as well as the eastern National Forest area, is rural in character, and similar in nature to the areas served by the demonstration project. Alliance guarantees its commitment to serving the homeless, persons without caregivers, and persons with AIDS, as well as others for whom hospice and palliative care is appropriate and beneficial. The applicant concludes that upon CON approval, Alliance’s Board of Directors will move quickly to recruit and hire an Executive Director who will identify best practices of the sponsors and use these to develop policies and procedures. Voyager HospiceCare, Inc. (CON #10022) states it is committed to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS. Voyager states it has developed admission criteria specific to HIV/AIDS that assists the staff in assessing the appropriateness of hospice admission11. Voyager has a policy in place that ensures patients (who do not have an available or capable primary caregiver) will receive support in developing an appropriate plan for when his or her condition necessitates full-time care. When a patient does not have an

11 Admission Criteria specific to HIV/AIDS can be found on pages 41 and 42, CON Application #10022.


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available or capable caregiver, the applicant states the social worker will assist the patient in developing a plan to continue to receive care in the event the patient is no longer able to manage living or being alone. Voyager also states it commitment to serving the homeless and it will work with homeless patients to find an appropriate residential setting for him/her in which hospice care can be provided.

(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 3B consists of Marion County. This criterion is not applicable to this review.

(5) Preference shall be given to an applicant who proposes to provide services that are not specifically covered by private insurance, Medicaid, or Medicare.

Adventa Hospice Services of Florida, Inc. (CON #10016) proposes to provide a number of services which are not covered by private insurance, Medicaid, or Medicare. These include: 13 months of bereavement care; volunteer recruitment, training, and supervision; community education including culturally competent presentations of the availability of hospice care to Hispanic and African-American groups; charity and indigent care; and through the Christen Foundation, assistance with household necessities. HCR Manor Care Services of Florida, Inc. (CON #10017) (Heartland Hospice) has agreed to condition this application with a commitment of a $10,000 patient/family special needs fund for the first year of operation of the Subdistrict 3B hospice specifically designated for programs and services outside of Medicare hospice benefit. Such programs may include medical transportation, private duty caregivers, housing, burial funds, music/pet therapist and massage/other alternative therapies. The applicant states that in addition to the core hospice services, including continuous care during periods of crisis and bereavement services, Heartland Hospice has established a program of Caring Promises that is currently employed by the hospices in Subdistrict 4A.


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The Heartland Caring Promises are as follows: • We promise to care for the mind, body, and spirit. • We promise to provide care that is comforting and

compassionate. • We promise to respect patient and family choices. • We promise to unite with community partners in care. • We promise to be accepting and supportive of patients wherever

they are in life’s journey.

The applicant states that it has also implemented several bereavement programs throughout the nation with grant funding from the Hospice Memorial Fund, including: • Children’s Grief Camp, “Camp Heartland” which provided an

outlet for children ages three to 15 to express themselves and ease their grief. Activities included horseback riding, pet therapy, basketball, beadwork, swimming, hayrides, camp fires and dancing. The children also made “memory boxes” in memory of their loved one, and participated in a balloon release memorial service.

• Heartland commits to develop, in year two, a children’s and family retreat program(s) to serve the residents of Service Area 3B. These programs will augment traditional bereavement services especially for children experiencing grief or loss.

• Bereavement support groups for teens works in conjunction

with the local school system to help teens verbalize their feelings and to discover healthy support systems. Teens participate in retreat weekends and activities, giveaways and a caring environment, helping them through the grieving process and assisting them in identifying ways to make important lifestyle decisions that will affect their future in a positive way.

• Community educational events and seminars, on topics such as “Palliative Chronic Disease Management: A Strategic Advantage” for health care providers and clinicians; and Alzheimer’s seminar for health care professionals and caregivers.

• Hospice educational materials are distributed to schools and

community agencies. A training program is conducted in schools for guidance counselors and social workers.


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• Heartland commits to create a public education program about the benefits of hospice care in Marion County.

• Workshops for volunteers to explore a fresh, innovative

approach to art as a healing medium.

Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) states it will provide services regardless of a patient’s ability to pay. Currently Cornerstone states it provides 7.14 percent in uncompensated care. The applicant also commits to provide resources to cover indigent needs for hospice care in Service Area 3B. Notes to Schedule 7A state that charity care amounts are based on actual percentage for Cornerstone Hospice and then increased in recognition of the socio economic factors for Marion County as indicated by the high Medicaid and Other Payer amount for self pay and indigent. Schedule 7A shows Medicaid accounts for 5.6 percent of total patient days for year one and two. “Other” care is projected to be 10.9 percent for years one and two. The following are specific non-covered services offered by Cornerstone: • Eighteen-month program for bereavement support provides

survivors with the social, psychological, emotional grief and bereavement support. Through risk assessments, supportive letters, and individual and group counseling Cornerstone’s bereavement team places the survivor at the center of bereavement care planning.

• Sand tray therapy utilizes large trays of sand along with objects,

toys, figures, etc. provided for a person to place in the sand to “tell a story” of how they are feeling that day. This therapy is helpful for children who are not articulate enough to express their feelings of loss and grief.

• Stepping stones community bereavement provides supportive

services to survivors in need, regardless of whether the deceased was a part of the hospice program providing individual and group counseling in school and work settings.

• Crisis counseling provided by bereavement counselors who are

specifically trained and certified to provide emergency response, stress debriefing and crisis counseling following a community disaster.


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• Life enrichment program offers the services of massage therapists, art, music, and aroma therapists to patients and families.

• Pet therapy

• Life review; a therapeutic technique helpful for patients to see

the totality of their life and to have a story to leave behind.

• Tuck-In program offered to patients who reside in assisted living facilities. Tuck-in nurses and home health aides visit hospice patients during the evening hours to assist with their personal needs and/or to provide symptom relief for the night.

• Intergenerational/Teen program selects high school students

and trains them to provide intergenerational volunteer services to hospice patients and their families.

• Children’s programs helps youngsters and teens understand

and deal with their feelings of anger, pain, guilt and isolation. Cornerstone has full-time children’s counselors dedicated to this program. Among other services offered are a children’s bereavement camp and a teen camp.

• Vigil Volunteers provide companionship to patients during their

time of dying. Most often needed in nursing home settings, vigil volunteers “fill-in” when family members are out of town or unavailable.

• Interfaith/Minority outreach program.

• Extended care provides necessities for patients and families

with special needs. This may include such things as emergency food, one-time utility payments, air-conditioning units, etc.

• Pathways program was developed in response to the

community’s need for palliative services for persons not yet ready for the depth of hospice services. The program offers specific, individualized services for people with a prognosis of six months to a year to live.

• Suicide prevention program.

• Ventilator removal program facilitates ventilator patients to

leave the hospital and transports them home to die.


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• Hospice veterans program.

• Community and professional education provides training in

E.P.E.C. (Education for Physicians on End of Life Care) and E.L.N.E.C. (End of Life Nurses Education Consortium). The training prepares physicians and nurses to present in-depth education and training to professional groups in the community.

• Cornerstone has initiated a partnership with Studer/Covenant

to “Hardwire Excellence.” The applicant states the program assists in developing leaders and aligning its goals within pillars of excellence: people, service, quality, finance and growth.

Odyssey HealthCare of Marion County, Inc. (CON #10019) states it will provide services that are not specifically covered by private insurance, Medicaid or Medicare. These services include: pet, music, massage, and aroma therapies, dialysis, palliative radiation, and palliative chemotherapy treatments. The applicant also notes services it provides in its existing hospice programs in Service Areas 11 and 4B. These services include: memory bear program, massage therapy, hospice education for the Hispanic community, chaplain provided funeral services free of charge, services to ventilator patients, music therapy and pet therapy services. VITAS Healthcare Corporation of Florida (CON #10020) states it will serve all medically qualified patients and their families who select the hospice care alternative. VITAS states it has made a strong commitment to serving patients regardless of their ability to pay and have provided in excess of one percent of revenues to charity care. For fiscal year 2007, the applicant states it provided 9.8 million in charity care. VHCF will provide the following “Non-Core Services” as a condition of approval of this application: • Commit to having every patient being assessed by a physician

upon admission to the hospice. • A physician will serve as a member of every care team and

provide patient visits as required.


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• 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. These measures will be recorded in Vx via a telephone call using the telephone keypad for data entry. At least 60 percent of patients reporting severe pain of seven to 10 will have their pain reduced to five or less within 48 hours of admission.

• Implement a pet therapy program to begin immediately.

VCHF states it will also provide the core services palliative radiation, chemotherapy and transfusions as appropriate for treating symptoms. VITAS states it invests significant resources each year to further research, education, training and delivery of service, all to the benefit of the patient and their family. HPH-Haven Alliance, Inc. (CON #10021) states that both sponsors, HPH and Haven, provide services for any patient in need regardless of their ability to pay. HPH conducts a variety of activities that benefit the communities it serves, but which are non-reimbursed, as follows: • Legacy Program – HPH provides equipment to the volunteer

department to record, edit, and produce a video tape of each patient’s memoirs.

• Teen Volunteer Program.

• Training Programs – HPH participates in a number of student

health care training programs with local colleges.

• Residential Care – HPH operates four separate residential units which provide an option for patients who have no caregiver or whose caregiver is unable to provide full-time care.

• Hospice service to children – pediatric support services are

mainly a non-reimbursed service to provide support services to children undergoing active treatment in the tri-county area served by Hernando-Pasco.

• Children’s Assistance Program- focuses on child bereavement

providing grief and support counseling partnering with school systems in the tri-county area.


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• Children’s Grief Camp – elementary school age children are offered the opportunity to participate in activities at these one-day camps to help improve their coping skills.

• Compassionate Paws – this is a special dog therapy program

managed under the Hernando-Pasco volunteer department.

The following are specific non-covered services offered by Haven Hospice: • Bereavement and grief support programs (available to all serve

area residents regardless of any relationship to Haven Hospice). Programs include: Individual and Family Grief Support; Anticipatory Grief Support for Children and Teens; Telephone Grief Support; Grief Support Groups; School Support Groups; Coping with the Holidays Programs; Community Outreach; Messages of Caring; SHARE (pregnancy and child loss) and Pet loss.

• Integrative and expressive therapies, such as music therapy, art therapy, massage therapy, and pet visitor program.

• Supportive counseling or consultation with patients or families addressing issues of serious illness even if they do not qualify for hospice benefit (Transitions Program).

• Non-health care related services such as homemaker services

and errands, as well as minor purchases to foster quality of life and maintenance at home, such as telephone installation and service or wheel chair ramp installation.

• Recruitment, training, and use of volunteers to augment Haven’s capabilities.

• Educational and support services for veterans.

• Services to citizens of other countries residing in Haven’s service area even if they have no hospice coverage.

Haven also offers counseling, support programs and services at businesses within its service area through its workplace counseling and support program. The applicant indicates that one of the duties of the newly hired Alliance Executive Director will be to


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inventory the best practices of the sponsors relative to non-reimbursable services and recommend them to the Board for approval. Voyager HospiceCare, Inc. (CON #10022) states it is committed to providing services that a patient might require or want even if the services are not covered by private insurance, Medicare, or Medicaid. Some of the non-covered services to be offered in Marion County are as follows: • Pet therapy program. • Extended bereavement services for up to a period of up to 16

months • Assisting patients with placements: Voyager assists patients in

completing Medicaid applications and getting placed into nursing homes or other appropriate residential settings.

• Physician continuing education programs. • Making final wishes come true.

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.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that Amydisys, Inc.’s Human Resources Department will coordinate the recruitment efforts for its hospice in Florida. The applicant goes on to outline the process by stating a needs assessment is conducted by position based on current volume of business affecting the particular agency. After the need of needed staff for each position is determined, the recruiting process begins. The applicant states that there are only a total of 6.84 FTEs needed for initial staffing. Some of these FTEs will be recruited from existing Amedisys Home Health Care staff. If additional persons are needed the applicant states it will use the following methods to recruit: classified advertising in local newspapers, trade journals or industry-specific publications; relationships with local nursing schools, especially LPN to


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RN bridge programs; use of outdoor/billboard advertising; internal employee referrals’ company web-site (www.amedisys.com) and link with www.monster.com; and direct mail pieces to professional licensure groups (nurses, therapists, other). The applicant goes on to state that orientation and training programs ensure that personnel are highly qualified and committed to provide quality services. The individual agency offers an intensive orientation program for all new staff. This training orients the staff to general operating procedures and provides customized clinical training depending on the experience of the individual. Staff members receive ongoing in-service education and have the opportunity to attend other workshops and seminars on new techniques and procedures. Staff members also receive compliance training at orientation and annually thereafter. The applicant states that retention of staff is insured through offering of benefits to full-time employees as well as through the company’s core beliefs. The applicant has also implemented a “hire to retire” program where incentive programs for all staff integrate clinical outcomes to financial performance. Staff At Start–up End Year One End Year Two

Director of Operations 1.00 FTE 1.00 FTE 1.00 FTE

Business Office Manager 1.00 FTE 1.00 FTE 1.00 FTE

Business Office Support 0.00 FTE 1.00 FTE 1.00 FTE

Account Executive 1.00 FTE 1.00 FTE 1.00 FTE

Community Education 1.00 FTE 1.00 FTE 1.00 FTE

Nursing (RN & LPN) 0.45 FTE 4.25 FTE 6.20 FTE

Dietician 0.03 FTE 0.24 FTE 0.25 FTE

MSW 0.18 FTE 1.70 FTE 2.48 FTE

Hospice Assistant 0.45 FTE 4.25 FTE 6.20 FTE

Chaplain 0.11 FTE 1.06 FTE 1.55 FTE

Bereavement Coordinator 0.50 FTE 0.50 FTE 0.50 FTE

Volunteer Coordinator 0.50 FTE 0.50 FTE 1.00 FTE

Intake Coordinator 0.00 FTE 1.00 FTE 1.00 FTE

Medical Director 0.12 FTE 0.12 FTE 0.12 FTE

Volunteers 0.50 FTE 1.30 FTE 1.70 FTE

Total 6.84 FTE 19.92 FTE 26.00 FTE Source: CON Application #10016, page 69.

HCR Manor Care Services of Florida II, Inc. (CON

#10017) (Heartland Hospice) states that the initial office will be fully staffed with an office manager, clerical support, director of professional services/patient care coordinator, and appropriate field staff. This proposed hospice program


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will follow the same staffing patterns that have served patients well in numerous other communities. The applicant listed the following as its standards of staffing: 1.0 FTE registered nurse and home health aide per 12 census, 60-70 percent of RN, home health aide staffing should be full-time employees, 1.0 FTE admissions nurse to do a minimum of 10-12 admissions per week, 1.0 FTE medical social worker per 25-30 census, 1.0 FTE administrator, 1.0 FTE office manager, 1.0 FTE clerical staff per 25 census (includes office manager, team coordinator, and receptionist, etc.) 1.0 FTE director of professional services, patient care coordinator per 50 census, 1.0 FTE Chaplain per 50 census, 1.0 FTE volunteer coordinator per 100 census, and 1.0 FTE bereavement coordinator per 80 census. The applicant has also listed conditions related to specialized staffing in Subdistrict 3B: • Heartland will contract 1.0 FTE physician specializing in

palliative care. • The applicant commits to provide 24-hour, seven days a

week, telephone response provided directly by Heartland Hospice staff.

• Heartland commits to address the specific needs of patients who are under age 65 and include information in clinical training programs to meet this identified community need.

• Heartland will provide specialized training for staff working with individuals with Alzheimer’s disease.

• Heartland commits that a staff member will contact all new patients within the next business day of admission and then again within seven days to ensure the patient/family needs are being met.

Schedule 6A shows a total of 14.8 FTEs for year one of operations and 23.96 FTEs for year two of operations. The applicant states that through the company’s existing network and initial public awareness campaign, Heartland Hospice expects no difficulty in recruiting the volunteers needed for the new hospice based on its successes in numerous other communities. HCR Manor Care states it will provide volunteer orientation and ongoing training to ensure that volunteers have the skills needed to assist patients and their families.


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Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) states it intends to staff the proposed hospice in Marion County with the same attention to high standards of care which it has provided throughout its current service areas for 25 years. The core services of administration, medical direction, nursing, social work, nursing aides, chaplaincy and volunteers will be directly hired by the hospice. The applicant states the geographic areas of Marion County that border Lake and Sumter Counties make a natural extension for staff and volunteers. The applicant states it has significant numbers of staff and volunteers, nearly 100, who work for Cornerstone but reside in Marion County which allows it to provide services to Marion County without depleting the current hospice Service Area 3B provider’s staff and volunteers. Recruitment and retention of staff are areas of business that Cornerstone states it values highly. Cornerstone asserts it spends a minimum of $128,000 on staff support and education annually. Such activities as team retreats, support groups, parties, gas cards, lunches, conferences and in-services assist staff to remain loyal and committed to Cornerstone. Additionally, Cornerstone states it recognizes the importance of offering flexible work schedules and alternative work environments. This attention to staff needs had meant a very low staff turn-over rate. Cornerstone also conducts annual compensation and benefit surveys to compare itself with local hospices and health care institutions. Cornerstone states it adjusts compensation to stay competitive within the market and retain staff. Schedule 6 shows the following staffing ratio: administration 5.0 FTEs, physicians 0.5 FTE, nursing 14.1 FTEs, dietary 0.1 FTE, social services 3.5 FTEs for a total of 23.2 FTEs for year one of operations. Year two is comprised of administration 5.0 FTEs, physicians 1.0 FTE, nursing 28.5 FTEs, dietary 0.1 FTE, social services 7.3 for a total of 41.9 FTEs for year two of operations. The applicant will contract for physical therapy, occupational therapy and speech therapy. Contracted nursing agencies will be used to provide intermittent shifts for crisis care when unable to fill from the Cornerstone nursing pool.


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Other non-staff contracted services include patient transport services, durable medical equipment/oxygen, pharmacy, infusion and lab. Odyssey Healthcare of Marion County, Inc. (CON #10019) states staffing forecasts presented in Schedule 6A reflect staffing necessary for the patient volume and levels of service expected for the proposed hospice. Included are 0.5 FTE for children’s hospice services and 0.5 FTE for community-wide bereavement programs, in addition to the typical bereavement staffing required by the projected volume and service mix. Schedule 6A shows the following staffing ratio: administration 9.0 FTEs, physicians 0.1 FTE, nursing 5.2 FTEs, dietary 0.3 FTE, social services 0.6 FTE for a total of 16.7 FTEs for year one of operation. Year two is comprised of administration 10.5 FTEs, physicians 0.1 FTE, nursing 15.4 FTEs, ancillary 3.9 FTEs, dietary 0.3 FTE, social services 1.6 FTEs for a year two total of 31.8 FTEs. The volunteer network of the proposed hospice will be modeled consistent with that of Odyssey’s programs nationwide. Volunteers can choose to work directly with hospice patients and families, in administrative activities at the hospice offices or in community functions, such as health fairs, memorial services or bereavement assistance meetings. VITAS Healthcare Corporation of Florida (CON #10020) states that some staffing positions and support functions will be provided via overhead allocation from the existing VHCF operations. These include but are not limited to the following: general bookkeeping, accounts payable and financial reporting, education and training, quality assurance, information technology and human resources which includes payroll and benefits administration. Volunteer staff hours are expected to equate to a minimum of five percent of employee time.


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Schedule 6A reflects the following: Position End Year One End Year Two

General Manager 1.00 FTE 1.00 FTE

Admissions/Hospice Reps 2.18 FTE 2.54 FTE

Bereavement Manager 0.50 FTE 1.00 FTE

Business Manager 0.58 FTE 1.00 FTE

PC Secretary 0.58 FTE 1.00 FTE

Receptionist 0.00 FTE 0.92 FTE

MedicalDirector/Physician 0.32 FTE 0.85 FTE

Team Director (RN) 1.00 FTE 2.08 FTE

LPN/Aides 5.75 FTE 20.48 FTE

On-Call Representatives 0.50 FTE 1.63 FTE

Social Worker 1.00 FTE 1.71 FTE

Chaplain 1.00 FTE 1.04 FTE

Total 16.66 FTE 41.25 FTE Source: CON Application #10020, page 89.

Dietary is a core service and cannot be provided for through contract services. The applicant does not have an FTE for dietary services on Schedule 6A.

HPH-Haven Alliance, Inc. (CON #10021) states Schedule 6A sets forth proposed staffing in detail for both years one and two of operations. By mutual agreement of the sponsors, these staffing ratios are based upon Hernando-Pasco Hospice’s and Haven Hospice’s current operations in neighboring service areas. Year one calls for hiring 17.0 FTEs to fully staff one new office and care team: administration 7.00 FTEs, physicians 0.25 FTE, nursing 5.50 FTEs, ancillary 1.00 FTE, dietary 0.25 FTE and social services 3.0 FTEs. Year two staff will increase to 22.75 FTEs, primarily in nursing and social services based on patient volumes: administration 7.00 FTEs, physicians 0.50 FTE, nursing 9.0 FTEs, ancillary 1.00 FTE, dietary 0.25 FTE and social services 5.0 FTEs. Although Schedule 6A presents only hired staff, Alliance states it will fully comply with the requirement for volunteer services including the development and implementation of a volunteer services program. Voyager HospiceCare, Inc. (CON #10022) staffing schedule is provided in Schedule 6A and indicates 12.77 FTEs in year one and 19.31 FTEs in year two. Year one FTEs are as follows: administration 5.50 FTEs, physicians 0.30 FTE, nursing 5.40 FTEs, ancillary 0.04 FTE, social services 1.5 FTE, and dietary 0.03 FTE. Year two FTEs are as follows:


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administration 6.33 FTEs, physicians 0.30 FTE, nursing 10.98 FTEs, ancillary 0.11 FTE, dietary 0.09 FTE, and social services 1.50 FTEs. Voyager states its staffing model utilizes an interdisciplinary group team including physicians, nurses, social workers, home health aides, bereavement coordinators, and volunteers. This team is called the Circle of Care and incorporates the patient and family in the center of this circle. The applicant states that with patient’s needs as top priority, the interdisciplinary team members work together to develop a plan of care to provide high quality palliative care for as long as required. Volunteers receive orientation and ongoing training throughout their time with the organization and are an integral part of hospice care.

(b) Expected sources of patient referrals.

Adventa Hospice Services of Florida, Inc. (CON #10016) provides the following as expected sources of patient referrals:

Projected Referrals to Adventa Hospice Services of Florida, Inc. Service Area 3B

Referral Source Percentage

Hospitals 30%

Physicians 30%

Skilled Nursing Homes 30%

Individuals and other 10%

Total Referrals 100% Source: CON Application #10016, page 71.

HCR Manor Care Services of Florida II, Inc. (CON

#10017) (Heartland Hospice) states that it will target a variety of sources for hospice referrals such as physicians, hospital discharge planners, social workers, nursing facilities, assisted living facilities, home health agencies, community social service agencies, churches, and veterans groups. The applicant received several letters of support for the project from local physicians and assisted living facilities that expect to refer patients to Heartland Hospice. Patients and families may also refer themselves with the support and direction of an attending physician. HCR Manor Care also


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plans to conduct a variety of marketing activities to let the community know of its presence as a hospice provider in the service area and has reserved a considerable portion of the funding for this project for community outreach initiatives. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) states it has previously completed two successful hospice expansions and has established policies, systems and start-up tables for transitioning into new areas. Cornerstone has provided its start-up schedule which details six months prior to opening time table. The applicant states its primary referral sources will be physicians, hospital case managers, family, friends, and relatives of patients who have previously used hospice services. The applicant states appendices IV, V, VI, VII, VIII, and IX, include letters of support and support statements from physicians, case managers, hospitals, facilities and community groups and residents in Marion County who will form the base of referral support. Cornerstone also states it has a well-developed community outreach/marketing department. Odyssey Healthcare of Marion County, Inc. (CON #10019) states it will actively seek patient referrals throughout the community. It is anticipated that referrals will originate from physicians, long-term care facilities; including nursing homes, assisted living facilities, and adult care centers, hospitals, managed care companies, and insurance companies. In each of the markets it serves, Odyssey states it has implemented a community education plan designed to address the specific needs of the patient referral sources in that market and to promote the quality, responsive and comprehensive service that Odyssey provides to its patients and their families. The applicant plans to implement this community model in the proposed hospice program as well. VITAS Healthcare Corporation of Florida (CON #10020) believes that due to the area need for hospice care and the quality of service VHCF intends to provide, attracting patients will not be difficult. The applicant expects referrals to come from area physicians, hospitals, nursing homes and other health care providers, family members and the patients themselves. As evidenced in the initial letters of support, the applicant states, cancer centers, doctors, assisted living facilities, nursing homes, hospitals, ministers and community residents all indicated their support of VHCF to


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establish a hospice program in Service Area 3B. The applicant states it will develop programs and services geared towards Service Area 3B referral sources. These programs are meant to enhance education about hospice services, pain and symptom management, the concept underlying intensive palliative care, VHCF’s mission, vision and objectives and serve to introduce the interdisciplinary team to existing providers of health care and custodial services.

HPH-Haven Alliance, Inc. (CON #10021) states that it is not valid to simply sum the raw numbers of referrals by source for the two sponsors and then divide each by the combined total referrals to come up with a combined average for each referral category. There are marked differences in the areas historically served by each of the sponsors, and variations in the percentages by category between the two is completely expected because specially targeted outreach approaches will vary based upon the unique needs of different communities. The applicant states that a common theme emerges when the referral percentages are viewed from a rank order perspective; in both cases hospitals are the number one referral source for both Haven and HPH, followed second by physicians, patients/families, skilled nursing facilities/assisted living facilities, and then other referral sources. The applicant anticipates its leading referral source from Service Area 3B will be hospitals and physicians (especially oncologists) due to the apparent under service to cancer patients, followed by skilled nursing facilities/assisted living facilities resulting from the issues that surfaced in discussion with representatives of this provider group. Voyager HospiceCare, Inc. (CON #10022) states it is expected that patient referrals for hospice services will come from a number of services including physicians, hospitals, skilled nursing facilities, retirement homes, and assisted living facilities within Marion County. Voyager states it has already started developing relationships and connections with Marion County health care providers, social service agencies, and religious organizations in order to educate them on the hospice services it can provide to area residents.


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(c) Projected number of admissions, by payer type,

including Medicare, Medicaid, private insurance, self-pay, 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 applicant.

Total Projected Admissions By Applicant for Years One and Two

CON # Applicant Year One Year Two

10016 Adventa 154 256

10017 Heartland 219 349

10018 Cornerstone 137 457

10019 Odyssey 285 405

10020 VITAS 193 418

10021 HPH-Haven 126 241

10022 Voyager 124 346 Source: CON Application #’s 10016-10022.

Adventa Hospice Services of Florida, Inc. (CON #10016) expects Medicare to comprise about 84.63 percent of the admissions during the first two years of operation and provided the following table for illustration.

Expected Admissions by Payer Type For Adventa Hospice Services for Florida, Inc.

Service Area 3B Payer Type Year One Year Two

Medicare 129 218

Medicaid 10 17

Private-Insurance 10 14

Self-Pay 1 1

Indigent 4 6 Total 154 256

Source: CON Application #10016, page 72.

As shown in the table above, the applicant intends to serve 154 and 256 patients in its first and second year of operation respectively. It is noted that the applicant’s provision of charity care is referenced in this table and will comprise 2.43 percent of admissions during the first two years of operations. HCR Manor Care Services of Florida II, Inc. (CON

#10017) (Heartland Hospice) provided the following table illustrating its projected patient days by level of care for the first two years of operation.


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Projected Number of Patient Days by Payer Type

For Heartland Hospice Service Area 3B

Payer Type Year One Year Two

Medicare 9,799 20,300

Medicaid 679 1,407

3rd Party Insurance 252 522

Self-Pay 110 227

Charity/Other 110 227 Total 10,950 22,685 Source: CON Application #10017, page 71.

The applicant intends to serve 219 and 349 patients in its first and second year of operation respectively. It is noted that the applicant’s provision of Medicare will comprise 89.48 percent of patient days during the first two years of operations and charity care/other will comprise one percent. However, HCR does not provide the number of admissions by payer type. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.

Projected Number of Admissions By Payer Type For Cornerstone Hospice, Inc.


Medicare 108 361

Medicaid 8 20

Insurance 6 26

Indigent/Self-Pay 15 50 Total 137 457


As shown in the table above, the applicant intends to serve 137 and 457 patients in its first and second year of operations respectively. It is noted that the applicant’s provision of Medicare will comprise 78.95 percent of admissions during the first two years of operations and indigent/self-pay will comprise 10.9 percent. Odyssey Healthcare of Marion County, Inc. (CON #10019) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.


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Projected Number of Admissions By Payer Type For Odyssey Healthcare of Marion County, Inc.


Medicare 264 377

Medicaid 9 12

Insurance 6 8

Self-Pay 6 8 Total 285 405


As shown in the table above, the applicant intends to serve 285 and 405 patients in its first and second year of operations respectively. It is noted that the applicant’s provision of Medicare will comprise 92.89 percent of admissions during the first two years of operations and self-pay will comprise 2.0 percent. VITAS Healthcare Corporation of Florida (CON #10020) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.

Projected Number of Admissions By Payer Type For VITAS Healthcare Corporation of Florida


Medicare 154 359

Medicaid 14 33

Insurance/Managed Care 9 21

Indigent 16 4 Total 193 418


As shown in the table above, the applicant intends to serve 193 and 418 patients in its first and second year of operations respectively. It is noted that the applicant’s provision of Medicare will comprise 83.96 percent of admissions during the first two years of operations and charity care will comprise 3.3 percent of admissions. HPH-Haven Alliance, Inc. (CON #10021) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.


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Projected Number of Admissions By Payer Type

For HPH-Haven Alliance, Inc. Service Area 3B

Payer Type Year One Year Two

Medicare 106 204

Medicaid 9 16

Private Insurance 6 12

Charity/Self-Pay 5 9 Total 126 241


As shown in the table above, the applicant intends to serve 126 and 241 patients in its first and second year of operations respectively. It is noted that the applicant’s provision of Medicare will comprise 84.46 percent of admissions during the first two years of operations and charity/self-pay will comprise 3.7 percent. Voyager HospiceCare, Inc. (CON #10022) provided the following table illustrating its projected number of admissions by payer type for the first two years of operation.

Projected Number of Admissions By Payer Type For Voyager HospiceCare, Inc.


Medicare 106 306

Medicaid 6 16

Private Insurance 7 19

Charity 5 5 Total 124 346


As shown in the table above, the applicant intends to serve 124 and 346 patients in its first and second year of operations respectively. It is noted that the applicant’s provision of Medicare will comprise approximately 87.65 percent of admissions during year two of operations and charity will comprise 2.1 percent.

(d) Projected number of admissions, by type of terminal illness, for the first two years of operation.

Adventa Hospice Services of Florida, Inc. (CON #10016) provided the following number of admissions by type of terminal illness:


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Projected number of Admissions by Diagnosis For Adventa Hospice Services of Florida, Inc.

Service Area 3B Disease Year One Year Two

Cancer 24 41

Non-Cancer 130 215

Total 154 256 Source: CON Application #10016, page 73.

According to the information provided the applicant projects to serve 154 patients by year one and 256 by the end of year two of operation, 345 of which will be non-cancer patients (years one and two combined). HCR Manor Care Services of Florida II, Inc. (CON

#10017) (Heartland Hospice) provided 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 Heartland Hospice, Inc.


Cancer 84 133

Non-Cancer 135 216


The applicant projects to serve 219 patients in year one and 349 patients in year two. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) does not provide this information. Odyssey Healthcare of Marion County, Inc. (CON #10019) provided the following number of admission by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For Odyssey Healthcare of Marion County, Inc.


Cancer 88 126

Alzheimer’s/Dementia 48 69

CHF 51 73

COPD 23 32

Debility 26 36

Renal 9 12

Liver/Other 40 57



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The applicant projects to serve 285 patients by the end of year one and 405 patients by the end of year two. VITAS Healthcare Corporation of Florida (CON #10020) provided the following number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For VITAS Healthcare Corporation of Florida


Cancer 95 188

HIV/AIDS 3 7

Respiratory 15 25

Cardiac 40 90

Renal Failure 3 10

Alzheimer/Cerebral Degen. 20 35

Cerebrovascular/Stroke 10 24

Other 8 39


The applicant projects to serve 194 patients by the end of year one and 418 by the end of year two.

HPH-Haven Alliance, Inc. (CON #10021) provided the following number of admissions by type of terminal illness for the first two years of operation.

Projected number of Admissions by Diagnosis For HPH-Haven Hospice, Inc.


Cancer 51 96

Non-Cancer 76 144


The applicant projects to serve 127 patients by the end of year one of operations and 240 by the end of year two. Voyager HospiceCare, Inc. (CON #10022) provided the following number of admissions by type of terminal illness for the first two years of operation.


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Projected number of Admissions by Diagnosis

For Voyager HospiceCare, Inc. Service Area 3B

Disease Year One Year Two

Cancer 60 175

Neurology 29 72

Pulmonary 12 34

Heart 12 34

Stroke 6 16

Renal Failure 5 15


According to the information provided the applicant projects to serve 124 patients by the end of year one, and 346 patients by the end of year two.

(e) Projected number of admissions, by two age groups, under 65 and 65 or older, for the first two years of operation.

Adventa Hospice Services of Florida, Inc. (CON #10016) projects the following admissions by age cohorts.

Projected Admissions by Age Group for Adventa Hospice Service of Florida, Inc.

Service Area 3B Under 65 Over 65 Total

Year One 19 135 154

Year Two 31 225 256 Source: CON Application #10016, page 73.

The applicant expects most of its patients in Hospice Service Area 3B to be over 65. In year one and year two, 87.8 percent of patients will be over 65. HCR Manor Care Services of Florida II, Inc. (CON

#10017) provides the following table for the projected number of admissions by age cohort.

Projected Admissions by Age Group for HCR Manor Care Services of Florida II, Inc.


Year One 34 185 219



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Hospice Lake & Sumter, Inc. (CON #10018) did not provide this information. Odyssey HealthCare of Marion County, Inc. (CON

#10019) provided the following table regarding the projected number of admissions by age cohort.

Projected Admissions by Age Group for Odyssey HealthCare of Marion County, Inc.


Year One 29 256 285


VITAS Healthcare Corporation of Florida (CON #10020) provided the following table regarding the projected number of admissions by age cohort.

Projected Admissions by Age Group for VITAS Healthcare Corporation of Florida


Year One 29 165 194


HPH-Haven Alliance, Inc. (CON #10021) provided the following table regarding the projected number of admissions by two age cohorts, under 65 and 65 or older, for the first two years of operation.

Projected Admissions by Age Group for HPH-Haven Alliance, Inc.


Year One 21 106 127


Voyager HospiceCare, Inc. (CON #10022) provided the following table regarding the projected number of admissions by two age cohorts, under 65 and 65 or older, for the first two years of operation.


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Projected Admissions by Age Group for

Voyager HospiceCare, Inc. Service Area 3B

Under 65 Over 65 Total

Year One 24 100 124


(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. Adventa Hospice Services of Florida, Inc. (CON #10016) states it will hire staff that provides the following services: physician services – responsible for the overall medical direction of hospice program; nursing services – responsible for the supervision, management, coordination and provision of quality patient care; home health aide services – provides support services, under the supervision of the appropriate professional staff in accordance with state regulations; dietary counseling; social work services, and counseling services- social workers and counselors assist and counsel hospice patients and families with health related financial, social and emotion concerns; Chaplain services; bereavement services – responsible for the provision of spiritual care services to patients/families/ caregivers; volunteers - will provide assistance to families and caregivers or direct care volunteers, assistance in administration and support services, and special projects which include fundraising. The applicant states that it will contract for physical therapy, speech therapy, occupational therapy, inpatient hospice care, and volunteers. HCR Manor Care Services of Florida II, Inc. (CON

#10017) asserts that with the exception of physicians, hospice core services will be provided by the hospice care


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team, including volunteers. When needed, contract services are determined on an individualized basis by attending physician. The applicant indicates that contract services are authorized in advance and provided with the ongoing awareness and input of multidisciplinary team. The multidisciplinary team consists of: • Medical director and attending physician • RNs and LPNs (hospice staff) • Social workers (hospice staff) • Home health aide (hospice staff) • Physical therapists/assistants (contract) • Occupational therapists/assistants (contract) • Speech and language pathologists (contract) • Paraprofessionals (homemakers, companions, aides)

(hospice staff) • Spiritual counselors (hospice staff) • Pharmacist (contract) • Registered dietitians (hospice staff) • Durable medical equipment (contract) Hospice of Lake and Sumter, Inc. (CON #10018) indicates on page 81 of the application that administrative support, medical direction/physician services, nursing, on-call services, home health aides, homemaker/chore services, dietary/nutrition and certified nurses assistants, social workers, chaplains, bereavement counselors, clinicians, clinical liaisons, interfaith/minority outreach staff and pool staff will be provided directly. Contracted arrangements will be physical therapy, occupational therapy and speech therapy. Contracted nursing agencies will be used to provide intermittent shifts for crisis care when Cornerstone’s nursing pool is unable to do so. Non-staff contracted services include patient transport services, durable medical equipment/oxygen, pharmacy, infusion and lab. Odyssey Healthcare of Marion County, Inc. (CON #10019) states that with the exception of physicians and a minimal level of contract care provided by physical, speech, and occupational therapists, the vast majority of hospice services will be provided by the hospice care team, including volunteers. In addition to the nurse case manager, the patient’s attending physician and the medical director, the applicant’s disciplinary team will include: a home health care aide, chaplain, social worker, volunteers, bereavement


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coordinator, and on-call nursing team. Other specialists, such as nutritionists and physical, speech or occupational therapists are a part of the applicant’s core services and are added to the patient’s team as needed. VITAS Healthcare Corporation of Florida (CON #10020) states that core services including physician services, nursing services, social work services, pastoral/counseling, dietary counseling will be provided for by VITAS staff and volunteers. The applicant states it will contract for certain services as needed. At this time, the applicant states it anticipates having all but durable medical equipment and supplies as well as pharmacy services provided by employees. However the applicant recognizes that there may be a need to supplement employed staff in certain functions such as physical-therapy, speech-language pathology, massage therapy and occupational therapy. According to Schedule 6, the applicant has no FTE for dietary services.

HPH-Haven Alliance, Inc. (CON #10021) states its sponsors have determined that Alliance hospice will provide the following services directly by hospice staff and volunteers: • Nursing services • Social work services • Pastoral & counseling services • Dietary counseling • Bereavement counseling services • Home health aides • Pharmacy services • Supplies and durable medical equipment • Homemaker & chore services • Physician services The following additional services will be provided through contractual arrangement: • Medical supplies and durable medical equipment (DME)

(to be contracted from the sponsors, as appropriate) • Pharmaceuticals, biologicals and pharmacy services • Physical, occupational, & speech therapy • Patient transportation services


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• Infusion therapy • Inpatient hospice care (initially) • Inpatient respite care Voyager HospiceCare, Inc. (CON #10022) states it will provide core services directly by its hospice staff and volunteers. Core services include nursing services, bereavement services, home health aide services, and dietary services, etc. The following services will be provided through contractual arrangements: • General inpatient and respite services. • Physician services. • Medication, supplies, home medical equipment. • Aggressive palliative care (radiation therapy,

chemotherapy). • Continuous care (this will be a combination of direct staff

and contractual arrangements with staffing agencies). • Physical, occupational, and speech therapists. • Triage/intake nurse services

(g) Proposed arrangements for providing inpatient care.

Adventa Hospice Services of Florida, Inc. (CON #10016) states it will contract with area hospitals or nursing homes in Subdistrict 3B to provide inpatient hospice care. The application includes a sample of a hospital contract used by Adventa in Appendix I. HCR Manor Care Services of Florida II, Inc. (CON

#10017) (Heartland Hospice) will initially arrange for providing inpatient care through contractual arrangements with hospitals and nursing homes. Heartland Hospice has received letters of intent from Palm Garden of Ocala and Marion House Health Care Center to contract for the provision of inpatient beds. The applicant does not propose to construct a freestanding inpatient hospice facility at this time. The applicant states that hospice care will be under the direct administration of the hospice, whether the inpatient facility is located in a nursing home or a hospital. The applicant provided evidence of local support for the project and its ability to secure contracts for services.


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Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) indicates on page 62 of the application that the patient may be hospitalized, placed in a skilled nursing home setting or be cared for in an inpatient hospice home. The applicant indicates that it has contacted all the hospitals in Marion County to explore contracting relationships for hospice patients. The applicant cites its letters of support from Oakhurst Rehabilitation & Nursing Center, Marion House and Palm Garden of Ocala and indicates that in-patient contracts will be completed once the project is approved. Odyssey Healthcare of Marion County, Inc. (CON #10019) states it will arrange for providing inpatient care through contractual arrangements with hospitals, nursing homes and other appropriate settings. The applicant will contract with acute care providers and skilled nursing facilities throughout Subdistrict 3B and has already reached an agreement with one skilled nursing facility for general inpatient care (Appendix D). VITAS Healthcare Corporation of Florida (CON #10020) states it will comply with applicable requirements as it applies to hospice physical plant standards. The applicant states its intent to have contractual agreements with nursing homes and hospitals designed to meet patient needs in Service Area 3B. VITAS notes it success with obtaining contractual service agreements in other service areas and anticipate the same success in Service Area 3B.

HPH-Haven Alliance, Inc. (CON #10021) states its two sponsors have extensive experience in provision of the hospice inpatient care component of their hospice programs. HPH states it maintains hospice inpatient care contracts with every hospital in the tri-county area of Citrus, Hernando and Pasco Counties. Haven Hospice asserts it is experienced in providing inpatient care directly, through its own inpatient units in Service Area 3A, and in leased space in Service Area 4A, as well as through contractual arrangements with existing nursing homes and hospitals throughout its existing 16-county service area. Alliance states it has received letters from three nursing homes in Marion County indicating willingness to contract for


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inpatient hospice care beds. Alliance had four nursing homes indicate willingness “to provide higher levels of care to our patients within our facilities”. Alliance intends to apply for certificate of need to establish a freestanding and dedicated licensed hospice inpatient care center of at least 12 beds in Service Area 3B by the end of year three of operations. Voyager HospiceCare, Inc. (CON #10022) states it will contract with existing hospitals and skilled nursing facilities in Marion County to provide inpatient beds. Voyager states it has received two letters of willingness to contract for inpatient beds from Ocala Health and Rehabilitation in Ocala, Marion County and from Palm Garden of Ocala12.

(h) Proposed number of inpatient beds that will be located in a freestanding inpatient facility, in hospitals, and in nursing homes.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that based upon Amedisys experience in providing contracted inpatient hospice care in other hospices, they anticipate that in year one about 196 patient days and in year two about 390 patient days will be needed to provide inpatient care. The applicant goes on to state that approximately 0.50 FTE inpatient bed would be needed over the course of year one and 1.1 FTE beds over the course of year two would be needed. HCR Manor Care Services of Florida II, Inc. (CON

#10017) did not provide a number of expected inpatient beds but rather proposes to contract for inpatient beds with existing providers.

Hospice of Lake & Sumter, Inc. (CON #10018) does not directly respond to this but indicates on page 63 that there are four hospice houses in Marion County and 62 hospice beds13. The applicant concludes therefore, there is no need for additional hospice house beds in Marion County. There

12 Willingness to contract for services letters are provided in Attachment J, CON Application #10022. 13 AHCA Hospice licensure records indicate that there are four residential hospices with 64 residential beds.


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is no medical inpatient hospice house in Marion County. As previously stated, the applicant indicates it will use hospitals and nursing homes for inpatient care. Odyssey Healthcare of Marion County, Inc. (CON #10019) states it is projecting 285 hospice admission the first year of operation and 405 hospice admissions the second year. No inpatient beds are proposed in this certificate of need application. Odyssey states it will arrange for the provision of inpatient care through contractual arrangements with hospitals, nursing homes and other settings throughout Subdistrict 3B. The applicant states it will establish arrangements with local nursing homes and/or adult congregate living facilities to ensure that patients in these types of facilities can remain in their “home” and receive hospice service. VITAS Healthcare Corporation of Florida (CON #10020) states its intent to have contractual agreements with existing facilities throughout the subdistrict. The applicant states it has started to establish relationships with Marion County’s three short term care hospital providers, one long-term acute care hospital and nine nursing homes: Munroe Regional Medical Center, Ocala Regional Medical Center, West Marion Community Hospital, Kindred Hospital in Ocala, Timberridge Nursing and Rehab, Palm Garden of Ocala, Oakhurst Rehab and Nursing Center, Ocala Health & Rehab Center, New Horizon Rehabilitation Center, Oakwood Nursing Center, Hawthorne Health and Rehab of Ocala, Life Care Center of Ocala, Marion House Health Care Center. VHCF states it will not be constructing beds and will contact for existing beds on an as needed basis, it has no intent on increasing the total number of beds available by facility.

HPH-Haven Alliance, Inc. (CON #10021) states it does not propose to build a freestanding inpatient hospice facility in Service Area 3B, so it has no expectation of locating any beds in such a facility to provide inpatient care. The applicant has proposed a condition that it will apply for a CON by the end of the third year of operation to establish a licensed freestanding inpatient facility of at least 12 beds.


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The applicant states that the six percent of total patient days anticipated to be devoted to hospice inpatient care will result in a very low average daily inpatient census of approximately one during year one and three in year two. Alliance states it will meet its needs for inpatient care through contractual agreements with Marion County hospitals and nursing homes. The beds accessed in this way are not expected to be dedicated or reserved beds, but will be available on an “as needed” basis under the terms of its agreements.

Voyager HealthCare, Inc. (CON #10022) states it intends to enter into contractual agreements with hospitals and nursing homes in Marion County to provide inpatient care to hospice patients when needed. Voyager states it is not proposing to construct a freestanding inpatient hospice facility but instead will utilize existing beds in the county.

(i) Circumstances under which a patient would be admitted to an inpatient bed.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that two types of events would require admission to an inpatient bed. One is to provide relief to patient caregivers. This type of inpatient care is reimbursed for up to five days for a given stay. The second event is for pain control or management of acute or chronic medical problems requiring inpatient hospital, nursing home, or hospice facility management. This care is provided when no other venue for symptom control is effective. HCR Manor Care Services of Florida II, Inc. (CON

#10017) states that inpatient care is dictated by a patient’s medical need. If possible, symptoms are addressed in the patient’s home environment. Occasionally this is not possible due to the nature of the symptoms, the level of caregiving support available, or patient or family wishes. The applicant states that at that point, hospice patients are encouraged to seek the level of care with which they are most comfortable, up to and including inpatient hospice care. Based on their need, inpatient, residential or an alternative mode of care is provided.

Hospice of Lake & Sumter, Inc. (CON #10018) indicates on page 62 of the application that there are times when a patient’s condition results in acute exacerbation of


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symptoms that are related to the terminal diagnosis and require skilled care that is not always possible in the home care setting patient. There may also be short-term crisis to control pain and when these instances occur, the patient may be hospitalized, placed in a skilled nursing home setting or be cared for in an inpatient hospice home. Odyssey Healthcare of Marion County, Inc. (CON #10019) states that inpatient care is dictated by a patient’s medical need. If possible, symptoms are addressed and care is provided in the “home” setting wherever that may be. Occasionally this is not possible due to the need to manage acute symptomology that cannot be effectively managed in the home setting, and when continuous care is not an option due to the level of caregiver support available, or patient or family wishes. The applicant states that at this point, hospice patients are encouraged to seek the level of care with which they are most comfortable, including inpatient hospice care. Based on the need Odyssey will secure inpatient contacts with hospitals and nursing homes in Service Area 3B. VITAS Healthcare Corporation of Florida (CON #10020) states circumstances under which a patient will be admitted to an inpatient bed vary depending upon the patient’s physical condition, which fluctuates with time, and the home care situation. Hospice patients may also be admitted if their pain/symptoms cannot be managed adequately at home. This is often a temporary situation for which inpatient care is recommended to help adjust the patient’s medications and reassess and regulate the care services to be provided.

HPH-Haven Alliance, Inc. (CON #10021) states that patients are admitted to an inpatient bed according to the guidelines set forth in the federal Medicare guidelines for hospice inpatient care. At the patients’ request and with their physician’s order, patients are admitted for management of severe symptom control, end-stage dying process, or medical crisis. The applicant goes on to state that the inpatient component of care is a short-term adjunct to hospice home care. The total number of inpatient days for all hospice patients in a 12-month period may not exceed 20 percent of the total number of hospice days. Both of the


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project sponsors, state that it is well below this proportion, providing just over six percent of total patient days to inpatient care in 2007. Voyager HospiceCare, Inc. (CON #10022) states it has policies in place that provide for hospice services in an inpatient bed to those patients that require such a service. Admissions decisions for short-term general inpatient care are made on an individual case-by-case basis after evaluation by the interdisciplinary group and in consultation with the patient’s attending physician. Voyager states it also provides respite services on a contracted basis with hospitals, nursing homes, and assisted living facilities.

(j) Provisions for serving persons without primary caregivers at home.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that it accepts patients without regard to their caregiver status. If the patient doesn’t have a caregiver then the patient is educated on how to identify someone who could come to assist at that point, such as a family member or friend. If that is not an option, then Adventa states it will attempt to locate a community resource such as nursing facility placement or ALF placement to support them. The applicant states that hospice is an intermittent care and they look for all the resources and opportunities to serve that patient’s needs and then write the plan of care around those resources. The applicant states it has never turned away a patient due to lack of caregiver. HCR Manor Care Services of Florida II, Inc. (CON

#10017) states that when a hospice patient can no longer care for himself, the plan of care requires a primary caregiver at the home or admission to a contracted long-term care facility or an alternate place where the patient’s safety can be secured14.

Hospice of Lake & Sumter, Inc. (CON #10018) did not address this criterion in this section but did address its commitment to serve patients who do not have primary

14 Refer to Appendix P for a copy of the Plan for Primary Caregiving, CON Application #10017.


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caregivers at home in the Agency Rule Preferences section. Cornerstone states it provides care regardless of a person’s ability to pay or the presence of a caregiver. Odyssey Healthcare of Marion County, Inc. (CON #10019) will provide services to all patients who meet the criteria for admission to hospice. Odyssey states that in the event a patient is impaired with physical problems that can no longer be managed at home, or the patient is homeless, the patient will be evaluated by a nurse for possible inpatient admission to a hospital or long-term care facility15. VITAS Healthcare Corporation of Florida (CON #10020) primary focus will be to enable patients to remain in the least restrictive and most emotionally supportive environment possible. Terminally ill patients with no at home support will receive increased attention from the hospice staff. According to VHCF, every effort will be made to develop a caregiver network from among neighbors, nearby relatives and friends, church members and hospice volunteers who will be capable of providing the necessary amount of supervision, assistance and companionship to the patient within the patient’s or caregiver’s home. VHCF states if the patient lives alone and does not have family or friends who live nearby and is able to care for him or herself for the most part, the applicant will assist the patient in developing a network of caregivers to assist the patient or recommend qualified adult sitter services be obtained should that not pose a financial hardship. The applicant may also recommend placement in an assisted living facility, or nursing home in which the applicant will be able to provide residential care.

HPH-Haven Alliance, Inc. (CON #10021) states that with the experience and support of the project’s sponsors, the commitment of Alliance Hospice to serve patients who do not have primary caregivers at home is guaranteed. The applicant will recruit and hire an executive director, if approved, whose first responsibility would be to identify best practices of the sponsors and to develop policies and procedures for serving persons without primary caregivers at home.

15 Refer to Appendix H, Odyssey Policy and Procedure Manuals Tables of Contents, including General Inpatient Care, and Access to Care Policies, CON Application #10019.


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Voyager HospiceCare, Inc. (CON #10022) states it is committed to serving all patients who require hospice care, including those without primary caregivers at home. Voyager insists it has a policy in place that ensures patients (who do not have an available or capable primary caregiver) will receive support in developing an appropriate plan for when his or her condition necessitates full-time care16. Voyager states when a patient does not have an available or capable caregiver, the social worker will assist the patient in developing a plan for continuing to receive care in the event the patient is no longer able to manage living or being alone. Voyager will assist the patient in deciding upon one or more of the following alternative options based on his or her individual needs: make arrangements with a family member or friend to live with the patient; make arrangements to move to the home of a family member or friend; hire a private duty caregiver to provide 24-hour live-in care, if needed; and move to a nursing facility, assisted living facility, hospice residence, or other location where his or her care needs can be met on a 24-hour basis.

(k) Arrangements for the provision of bereavement services.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that it provides for up to 13 months of bereavement support. Adventa states that system wide it provides the following levels of bereavement care: bereavement care for family and loved ones; bereavement and grief in the community; and bereavement and community memorial services. In addition to memorial services, the applicant states it provides very specific grief in-services for facility partners, for example during the holidays, on coping with grief during those times while also providing education to the community for very specific grief issues. The applicant provided 0.50 FTE in Schedule 6A for years one and two of operations for a bereavement coordinator. HCR Manor Care Services of Florida II, Inc. (CON

#10017) (Heartland) indicates that it has a strong commitment to providing bereavement services both to its surviving family members and the community at large. HCR Manor Care plans to employ a full-time bereavement

16 Policy Provided in Attachment M, CON Application #10022.


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coordinator (one per 80 census) in order to establish the types of bereavement programs that are provided throughout its national network of hospices. The applicant also proposes a children’s and family retreat program to be developed to augment traditional bereavement services, especially for children experiencing problematic grief. Schedule 6A provides 1.00 FTE for a bereavement coordinator for years one and two of operations. Hospice of Lake and Sumter, Inc. (CON #10018) (Cornerstone) has an 18-month program for bereavement support services for survivors with social, psychological, emotional grief and bereavement support needed during life’s difficult transition after the death of a loved one. Cornerstone states that through risk assessments, supportive letters, and individual and group counseling, its bereavement team places the survivor at the center of bereavement care planning. The applicant also provides examples of intervention techniques it utilizes for the grief process. Schedule 6A provides 1.2 FTEs in year one for chaplain/bereavement counselor and 2.6 FTEs in year two. Odyssey Healthcare of Marion County, Inc. (CON #10019) states that qualified hospice staff and volunteers will begin assessing needs for bereavement services upon admission of the hospice patient. A bereavement coordinator will be designated for managing the services of the bereavement program. Odyssey indicates that it offers condolence correspondence, written materials, articles, resources, one on one counseling, bereavement letters, grief support groups, memorial services, and holiday bereavement programs. The applicant also states that through the Odyssey HealthCare Foundation, Sky Camp is offered to children ages seven to 17. It is a free weekend camp for children grieving the death of a loved one; the camp provides a place for the children to feel safe and nurtured. The applicant commits 0.5 FTEs for the development of community bereavement services and the establishment of a Florida-based Children’s Bereavement Camp modeled after Odyssey’s existing Sky Camp. Schedule 6A provides 0.8 FTE in year one and 1.0 FTE in year two for a bereavement coordinator and 0.4 FTE in year one and 1.1 FTE in year two for a spiritual coordinator.


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VITAS Healthcare Corporation of Florida (CON #10020) states that its bereavement services are available 24 hours a day, seven days a week. Services will be based on the assessed needs of the family. Bereavement program is under the direction of a volunteer/bereavement manager. Review of the need for bereavement services begins with an initial assessment at the time of hospice admission. Services are provided to the family for up to one year after patient death, or longer than one year if needed. The applicant also states that contact is maintained with family members at one, three, six, nine, 12 and 15-month intervals. VITAS claims it provides the following to bereaved family members: a bereavement packet; follow-up letters; invitation to bereavement groups; annual memorial gatherings and a “Coping with the Holidays Program”. VITAS also notes that it has staff and volunteer bereavement support as well as family bereavement and that staff may utilize an employee assistance program. It commits 0.50 FTE in year one and 1.00 FTE in year two in its Schedule 6A to a volunteer/ bereavement manager.

HPH-Haven Alliance, Inc. (CON #10021) has decided that the approach used by HPH for the provision of bereavement services shall serve as the model for Alliance in Service Area 3B. HPH currently employs fifteen bereavement counselors and approximately 40 percent of HPH’s bereavement services are to non-hospice survivors. Bereavement services include home visits and assessments, eight-week bereavement support groups, holiday support groups, bereavement telephone support, specialized mailings, and time of remembrance services. The Children’s Assistance Program (CAP) provides special support for children of the hospice families served as well as community referrals. Services include home/and or school visits and assessments for grief counseling, specific referrals for trauma events, group counseling, hospice children, and child grief camps. The applicant states that the initial Alliance Hospice office will include space for grief and supportive counseling and bereavement activities, and space will be arranged in other locations to meet the access needs of the community or specific space requirements of various programs as they develop. The applicant provided 0.50 FTE in year one and 1.00 FTE in year two of operations for a bereavement counselor.


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Voyager HospiceCare, Inc. (CON #10022) has an organized program for the provision of bereavement services available to patient’s family members, caregivers, significant others, and to the community at large for 13 weeks following the patient’s death. Shortly after a patient’s admission to hospice, the applicant states that its interdisciplinary team identifies family members, caregivers, or significant others who are at risk for a complicated grief reaction and an initial risk assessment is completed. Bereavement services provided include, but are not limited to bereavement visits and counseling; letters and supportive informative mailings; telephone calls; support groups; and memorial services. Bereavement services are also provided to members of the community and may include support groups, community education, crisis counseling, and working with schools or businesses impacted by loss. The applicant has conditioned to extend bereavement services for up to 16 months. The applicant has provided 0.50 FTE for a bereavement coordinator for year one and two of operations.

(l) Proposed community education activities concerning hospice programs.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that it provides a wide range of community education in areas which it serves. The applicant anticipates providing a substantial number of community education programs through the activities of the designated full-time community educator. Adventa states it will also provide grief groups which are open to all members of the communities which it serves. HCR Manor Care Services of Florida II, Inc. (CON

#10018) (Heartland) states that its community education activities include meeting one-on-one with physicians and other health care professionals as well as formal educational programs. Formal programs include: frequent programs for the community address living with the loss of a loved one; presentation to Alzheimer’s support groups; guest lecturing at schools, churches, and professional organization; distribution of educational materials to schools, churches, and professional organizations; distribution of educational materials to school and community organizations; and publication of articles of interest and of education in local community newspapers. The applicant is proposing a


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considerable marketing campaign to launch its hospice into the service area and foster community support through regular and frequent educational seminars. By educating the public about the benefits of hospice care, utilization is expected to increase for all hospice providers in the area. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) does not directly address this specific criterion but did address its educational offerings on pages 81 and 82 providing a list of seven professional education classes it will extend to Marion County and provides a brief overview (pages 16-18) of start up activities involving focus groups and community advisory groups for its new hospice. Cornerstone asserts its commitment to providing hospice and palliative care education to health care professionals and hospice workers. The applicant states that in 2007-2008 over 1,300 educational programs were offered to physicians, case managers and other professional groups. Additionally, 1,400 public presentations and community outreach speeches were completed. Odyssey Healthcare of Marion County, Inc. (CON #10019) states that it will implement a community education plan to promote its services in the proposed area. The applicant states that three or more dedicated community education representatives will be available to call on patient referral sources and to educate health care providers in the area. The applicant states it will conduct local education campaigns that promote hospice care and seek to increase public awareness of hospice care. VITAS Healthcare Corporation of Florida (CON #10020) intends to seek community awareness through numerous mechanisms including public forums and seminars at churches, schools and other locations. The applicant plans to implement programs such as “Cool Kids Club” program that supports increased awareness of hospice opportunities and direct contact with the elderly, a “PetPals” program in which pet therapy is available, guest lecturers in private and public middle schools through colleges and “Bereavement Bears” in which VITAS volunteers sew bears from clothing of a lost loved one. VHCF states it will encourage employee involvement in community activities and provide financial contributions as it can and become a productive member of


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the health care and supportive services community through its involvement in community outreach activities throughout Subdistrict 3B.

HPH-Haven Alliance, Inc. (CON #10021) indicates that both its sponsors provide extensive community education activities concerning hospice programs. The applicant states that HPH participated in nearly 400 community events in 2007, where the public was educated concerning hospice programs. Haven also has a very active and effective community outreach and education program.

Haven Hospice states it has participated in a number of community education and outreach activities throughout 200717. Additionally Haven states it offers presentations to the general public free of charge on topics such as: alternative care - what is it? who needs it? who qualifies?; seasons of grief – preparing for the holidays; companionship in dying; wills and trusts; wise use of over-the-counter medications. Haven also offers a training class, An Introduction to Hospice, that is offered to and open to the public. In addition to the community outreach efforts aligned to educate the overall community, Haven Hospice employs professional liaisons consisting of 13 staff dedicated to the medical and health care professional organizations throughout the communities they serve. Voyager HospiceCare, Inc. (CON #10022) states it has an extensive program entitled Advanced Clinical Training Series, which educates staff and the community on various specific diseases such as end stage dementia, Alzheimer’s disease, end-stage pulmonary disease, and end-stage cardiac disease. Voyager also proposes to participate in senior expositions, health fairs, and public information forums.

17 Copies of sample brochures, informational flyers, and community outreach activities in Hernando-Pasco’s and Haven’s existing service areas provided in Tab 4, CON Application #10021.


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The applicant has conditioned to target its communication efforts, outreach programs for bereavement support services, and educational information on access and benefits of hospice and palliative care to those that are most influential with the population that are located in the lower-socio-economic areas of Marion County and that population that is most likely underserved.

(m) Fundraising activities. Adventa Hospice Services of Florida, Inc. (CON #10016) states that it has established a charitable foundation which provides certain non-reimbursable services to hospice patients and to home health patients among others. The Hospice Fund, administered by Amedisys’ Christen Foundation (parent company of Adventa Hospice, LLC), was founded to ensure support and financial assistance to terminally ill patients and their families. The applicant states that the fund can lend a helping hand to those patients and/or family members who may not have the financial resources to pay for basic needs such as food and utilities, or for medications and supplies to those who are not covered by Medicare, Medicaid, or other insurance hospice plans. In addition, the fund provides special grants for patients and/or family members to support last wishes, such as transportation to bring families together. Grants from the fund are also used for community activities, end-of-life care education, and bereavement services. The applicant asserts that the Christen Foundation relies on contributions. All donations and in-kind gifts are tax deductible under section 501 (c)(3) of the IRS Code and help support hospice care for those who otherwise could not pay. The applicant has conditioned that it will not solicit donations from Marion County residents or businesses for any Amedisys affiliated charity or foundation for five years. Adventa confirmed this in its response to this criterion. HCR Manor Care Services of Florida II, Inc. (CON

#10017) states that it established The Hospice Memorial Fund on October 1, 2001, a not-for-profit fund that distributes donations for community support and patient and family needs. Since some community and family needs


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are urgent in nature, the fund has a very fast turnaround time. Examples of services provided in the past include providing handicap accessible accommodations, transportation costs to visit a hospice patient and funds for local hospice and palliative serves and education. According to the applicant, total grants made from the fund totaled $1,054,195 between June 2007 and May 2008.

Hospice of Lake & Sumter, Inc. (CON #10018) states that it is sensitive to the dependence of a community-based hospice on philanthropic and donor dollars to support the ongoing and extended work of hospice. The applicant proposes as a condition to CON approval to not holding any major fundraising events such as golf tournaments within Marion County during the first two years of operation activities. Odyssey Healthcare of Marion County, Inc. (CON #10019) (Heartland) states that it will not perform any local fundraising activities in direct support of its operations; all program services and activities will be funded by the hospice’s operations. Rather the applicant states it will support existing community-based fundraising efforts including the fundraising efforts of local health care support groups and the existing hospice provider as well as the fundraising efforts of the Dream Foundation. The applicant’s parent, Odyssey HealthCare, has an active national contributions program. Past contributions of the Odyssey Foundation have been made to The National Hospice and Palliative Care Organization to develop a media-based program to educate the general public about hospice, and to fund the development and dissemination of research that assists hospices in caring for terminally ill children and to fund hospices in Romania and Sub-Saharan Africa, and Meals on Wheels. In 2006, the contributions program gave approximately $4.9 million in charity care back to the communities it serves and an additional $680,000 through the Odyssey Foundation. The applicant lists many services and “extras” that are not reimbursable.18

18 A list of services and extras provided by the applicant are listed on pages 202-203 of CON Application #10019.


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VITAS Healthcare Corporation of Florida (CON #10020) states that it does not actively raise funds from the community. The applicant also does not compete with other existing hospice organizations or other groups in obtaining funds from the community.

HPH-Haven Alliance, Inc. (CON #10021) states that it will engage in soft solicitation of support from the families and friends of those who it has served and does not anticipate that fundraising activities will play a significant role in its operations in Marion County.

Voyager Healthcare, Inc. (CON #10022) contends that as a for-profit hospice, it does not engage in fundraising activities nor does it request contributions from patient’s families. The applicant states that any donations or funds set up are primarily used to fund the care of uninsured and underinsured patients. These funds and contributions are also used to assist with providing community, volunteer, and professional staff education and training in a variety of fields. The applicant states it is important to Voyager that any donations or funds received are used within the community supporting end-of-life care, education, etc. The applicant has conditioned to not seek or solicit donations for at least the first two years of operation.

3. Statutory Review Criteria

a. Is need for the project evidenced by the availability, quality of care, efficiency, accessibility and extent of utilization of existing health care facilities and health services in the applicant’s service area? ss. 408.035(2), 408.035(7), 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 3B.

The following chart illustrates the increase in hospice admissions for the past five years. As shown below, admissions have increased from 1,654 in year ending December 31, 2003 to 2,236 in year ending December 31, 2007.


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Hospice Admissions for Service Area 3B

Calendar Years 2003-2007 Calendar Year Admissions

2007 2006 2005 2004 2003

2,236 2,233 1,970 1,937 1,654

Source: AHCA Florida Need Projections for Hospice Programs, published April 2004-April 2008.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that the availability of hospice care would be increased by the addition of another hospice program to serve Subdistrict 3B. The applicant states that after examining the number of persons who died in Subdistrict 3B in 2006 (3,990) and subtracting the number who received hospice care (2,233) there were 1,757 who reached end-of-life without benefit of hospice care. Therefore the applicant concludes that availability of hospice care would be increased by the addition of another hospice program to the service area. Adventa is part of the national hospice care provider Amedisys which provides care in 17 states in 47 existing hospice programs. The applicant states that it has an extensive quality improvement program and includes a copy of this in Appendix L. Adventa also states it will benefit from the operational experience of the management teams of the 47 hospice programs run by Amedisys and from the operation experience of Amedisys, Inc. management which owns and manages over 432 home health agencies. Adventa notes that access is more about delivery of care to those in need rather than about the physical location of the provider (other than that local offices increase community knowledge and availability). Adventa plans to improve access to care by campaigns of community education to groups who are thought to underutilize hospice services. These include: African Americans, Hispanics, homeless persons, and similar groups. Adventa states it has reviewed the levels of service needed in the subdistrict and finds that non-cancer patients of all ages are the most underserved patients in the area without access to hospice services. Adventa will focus many of its community education services on the needs of these non-cancer patients with end-of-life prognoses.

Adventa has provided evidence that it can obtain local support needed to provide the hospice services it proposes in this planning area.


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HCR Manor Care Services of Florida II, Inc. (CON #10017) (Heartland Hospice) states that the proposed project will enhance the availability, quality of care, efficiency, and accessibility of hospice services within Subdistrict 3B. The applicant asserts that hospice services should be promoted to such a degree that the average person is aware of hospice service and has access to them when needed. Targeted efforts will be implemented for other special needs populations to ensure that they are aware of the benefits of hospice care and have ready access. In particular, patients under 65 and Alzheimer patients will be sought out with special outreach efforts. By establishing a hospice program in the area, Heartland will be able to work with families of appropriate long-term patients in nursing centers and assisted living facilities to help them better understand the value of hospice care versus curative care, thereby improving availability and access. Heartland states its primary focus is on the continuous improvement of organizational performance. Essential activities include the design, measurement, assessment, and improvement of systems and processes to increase value and positively impact patient/family outcomes. The Heartland parent corporation is also a member of the National Hospice and Palliative Care Organization and adheres to its quality standards, as will Heartland Hospice. The applicant states it is not a stand-alone provider but is supported by an established network of quality health care resources, both nationally and in the State of Florida. Relationships with area hospitals, physicians, discharge planners and others, along with local and regional Heartland Hospice staff, will assure that the hospice benefit will be maximized within the subdistrict, resulting in improved quality and better coordination of care throughout the continuum of health care services. The applicant asserts that it is committed to addressing the specific needs of patients who are under age 65 and include information in clinical training programs to meet this identified community need. Heartland states it will also provide specialized training for staff working with individuals with Alzheimer’s disease to enhance the provision of hospice care to such individuals. The applicant also states that there is an opportunity to increase penetration rates in the subdistrict without adversely affecting the utilization of the existing provider and that it is the appropriate applicant to lead this effort. Hospice of Lake and Sumter, Inc. (CON #10018) (Cornerstone) states that it has a proven track record of excellence in establishing new hospice programs in adjacent service areas with quality, efficiency and cost-effectiveness. Cornerstone asserts its proposed hospice will increase availability, quality of care, efficiency, and accessibility of end-of-life care


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in Marion County. The development of another hospice committed to serving eligible patients, regardless of ability to pay, and available in underserved areas, greatly improves access for the indigent, Medicaid and AIDS clients throughout Service Area 3B. New offices and electronic communication stations in remote areas as well as specialty programs and bi-lingual staff, will unquestionably enhance availability, access and quality of care according to Cornerstone. Cornerstone states it has a proven track record of quality and customer service. The model plan for quality improvement will be adapted fro this new project with highly qualified people designated to review quality issues and improvement projects. Odyssey Healthcare of Marion County, Inc. (CON #10019) states that the need for this project is evidenced by the extent and the mix of utilization of the existing hospice program in the subdistrict. It is the applicant’s position that in addition to AHCA’s defined need, the existence of special circumstances in the Subdistrict confirms the need fro an additional hospice program: hospice admissions process not completed with in 48 hours, cancer patients over the age of 65 are underserved, and patients are inappropriately being moved from their “home” settings to obtain care. The applicant states that since competition between hospice providers is service-based rather than price-based, the introduction of another hospice provider will provide incentive for the sole existing hospice provider to improve and expand the level of service provided to the residents of Subdistrict 3B. Odyssey states it has the specific resources required to expand local service offerings and to provide the competition necessary to improve the level of hospice care provided in Subdistrict 3B. Specifically, in each of its markets served, Odyssey states it has implemented a community education plan designed to address the specific needs of the patients and patient referral sources in that market and to promote the quality responsive and comprehensive service that it provides to its patients and their families. Odyssey intends to implement a similar community education plan to meet the specific needs of the residents of Marion County. Odyssey states its organizational structure is designed to achieve a high level of patient and family satisfaction and to provide responsive quality care. Odyssey is in the process of implementing a new electronic clinical system to fully integrate billing and clinical systems. The new system will result in the reduction of hours required to perform the manual documentation processes currently in place, improve clinical documentation, improve employee satisfaction and provide real-time visibility of key measures for all locations. All caregivers will have access


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to up to date patient information, clinical documentation will be checked for accuracy and completeness at all points of service. Field staff will have on-line access to: medication interactions and education guidelines, and teach guides and policy and procedure manuals. The applicant states that the ultimate goal of this process is to enable staff to spend more time delivering quality care to patients and families and less time completing paperwork. Odyssey states it continually expands and refines its continuous quality improvement program. Specific written policies, procedures, training and educational materials and programs as well as auditing and monitoring activities, have been prepared and implemented to address the functional and operational aspects of hospice19. VITAS Healthcare Corporation of Florida (CON #10020) states that Subdistrict 3B is underserved with respect to market penetration. As determined by the need formula, in year one there is a published net need of 430 admissions for which the applicant projects meeting 45 percent or 194 of the published net need. Relative to its impact on existing providers, the applicant states that given the magnitude of community need and its focus on patients in need on continuous care, Veterans, non-cancer and cancer patients and ALF/SNF residents, and working collaboratively with Hospice of Marion County, there will be no adverse impact to patient volume at the existing hospice. VHCF states it is in compliance with the Conditions of Participation for hospice providers of services under the Health Insurance for the Aged and Disabled Program (Title XIII of the Social Security Act) as well as the Medicaid Program. VHCF also states it has many unique features which enhance quality of care and that these features are not provided by most not-for-profit hospices or other for-profit hospices. These include but are not limited to providing telecommunication resources for patients, specialized programs for specific illnesses or professions, culturally sensitive programs, 65 percent reduction in pain score within 48 hours, physician care team member, and patients examined by physicians upon admission. The applicant states it has not selected a site for the VHCF office, but if selected the office will be centrally located in Marion County to enable easy access by employees as may be necessary for their limited use of the central office. VITAS states that it provides services and presents no obstacles, and welcomes charity care patients. VITAS states that year

19 Refer to Appendix H, Odyssey Policy and Procedure Manuals Tables of Contents, CON Application #10019.


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after year, it provides in excess of one percent of revenues to charity care. For fiscal year 2007, this amount exceeded $9.8 million having increased from $8.5 million in 2006. VHCF states it will ensure staff is educated in the provision of appropriate, high quality, effective and efficient services enabling patients to receive the most appropriate pain and symptom management to meet their needs. VHCF intends to meet the underserved needs of the community using these methodologies as the tenets of quality and efficient service. VHCF also states it is committed to serving lower income communities and will develop unique partnership programs within these communities in an effort to increase access to hospice care.

HPH-Haven Alliance, Inc. (CON #10021) states that hospice services are not available and accessed to the extent needed by the residents of Subdistrict 3B. The applicant states that cancer patients of all ages are underserved, there is evidence that nursing home and ALF residents are underserved and that there is no hospice inpatient facility available to serve residents of the service area. The applicant goes on to state that since the rule and the need methodology incorporate issues of availability, accessibility, and extent of utilization, those issues by definition evidence need for the proposed project. The applicant states that it is well positioned to address the needs of cancer patients in the service area. The applicant states that one reason for the lower number of cancer admissions to hospice is due to the out migration of terminally ill cancer patients seeking hospital and physician oncology care at Shands Hospital at UF, Shands Cancer Center, Moffitt Cancer Center, and Tampa General Hospital. The applicant states that it has strong referral relationships with the above hospitals and that these relationships will facilitate the referral of terminal cancer patients residing in Marion County to a hospice program in their community.

The applicant also states that the volume of hospice patient admission in Service Area 3B justifies the development of a licensed hospice inpatient facility to serve terminally ill patients whose medical conditions demand this level of care. Alliance commits to applying for certificate of need for the development of an inpatient facility of at least 12 beds by the end of the third year of operation. Alliance has provided evidence that it can obtain local support needed to provide the hospice services it proposes in this planning area.


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Voyager HospiceCare, Inc. (CON #10022) will seek to expand the “top of mind” knowledge of the hospice benefit among cancer providers, patients, their families, eldercare and end-of-life organizations, and the community at large. These efforts will include but not be limited to providing annual seminars for physicians on hospice, expanding support groups, targeting outreach efforts particularly to geographic areas with populations that are likely to not seek care. Voyager intends to serve all residents requiring hospice services throughout the entire county; however, it will focus on areas which appear to be underserved, such as those communities in northern and north eastern half of the county. The applicant states that the growth in hospice admissions over the last five years and the identification of projected unmet need for hospice services in Marion County may indicate there is need for additional hospice resources to serve these markets. Voyager states it is committed to providing quality of care at the highest level to terminally ill patients and their families residing in Marion County. Voyager provided the following examples of ways it provides quality services and activities: commitment to compliance, program integrity process, annual agency evaluation compliance reports, commitment to compliance activities, staff education and certifications, clinical excellence through extensive training programs, 24-hour triage nurse, and patient, family, and referrer satisfaction surveys. Voyager states its commitment to compliance helps drive efficiency throughout the organization allowing it to do what’s right for the patient by focusing on the patient’s needs and not ways to maximize reimbursement. Voyager is conditioning the approval of its application to assure that it has plans in place to meet the needs of Service Area 3B. Conditions specific to this include locating the main office centrally in Marion County, implementing outreach programs, and providing ongoing education assistance to the residents and key referral sources that are aware of these pockets of population that may not be seeking hospice support.

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(3), Florida Statutes.

Adventa Hospice Services of Florida, Inc. (CON #10016) was formed in November 2007 and therefore has no operating history. But Adventa Hospice is wholly owned by Adventa Hospice, LLC which is in turn wholly owned by Amedysis, Inc.


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According to the applicant, Adventa Hospice, LLC operates hospice programs in 17 states including Alabama, Alaska, Colorado, Georgia, Idaho, Indiana, Kansas, Louisiana, New Hampshire, North Carolina, Oregon, Pennsylvania, Tennessee, Texas, Virginia, West Virginia and Wyoming. The applicant asserts that it has the ability to build upon the successful management of both Adventa Hospice, LLC and Amedisys, Inc. in preparing a strong platform on which to provide high quality care to the residents of Subdistrict 3B who need hospice care. The applicant states that the 55 separate home health services in Florida that are owned by Amedisys are all in regulatory compliance. The applicant provides a list of the home health offices in Appendix M. The applicant indicates that it holds national membership in the National Hospice and Palliative Care Organization and the National Association for Home Care and Hospice. The applicant also states that it is accredited by the Joint Commission.

HCR Manor Care Services of Florida II, Inc. (CON #10017) is a newly formed non-profit Florida corporation. The applicant has a brief hospice licensure history, with its hospice in Service Area 4A being licensed effective September 6, 2007. There have been no confirmed complaints as of July 23, 2008. HCR Manor Care Services of Florida II, Inc. is affiliated with HCR Manor Care, Inc., providers of nursing home, assisted living, home health and hospice services. Through its operating group Heartland Home Health and Hospice, the applicant states that Manor Care operates over 100 licensed hospice and home health agencies in 23 states, including six home health care agencies in Florida. Through the HCR Manor Care operating group, Manor Care operates approximately 340 nursing homes and assisted living facilities in 30 states, including 29 nursing homes and 13 assisted living facilities that are located in Florida. The applicant states that Heartland Home Health Care and Hospice is a member of the National Association for Home Care and Hospice (NAHC) and adopts its policies and procedures in the conduct of operations. Heartland Home Health Care and Hospice programs are also accredited by the Community Health Accreditation Program, Inc. (CHAP), an independent, non-profit accrediting body, first established in 1965.


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Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) states it sets exceptional state-of-the-art standards for care and its reputation for excellence comes from its dedication to continuous improvement. The applicant states that it follows the recommendations and standards of practice set forth by the National Hospice and Palliative Care Organization and is an active member and quality partner. Cornerstone states it has a comprehensive performance improvement and compliance program in place, that is revised each year to reflect the changing program or patient/family needs. Cornerstone’s approved quality improvement plan and thorough policy and procedures guide care delivery, are reviewed and updated as necessary to address changes in statute, rule, and industry best practices. The applicant states that one of the strongest, most consistent measures of quality for hospice programs is family surveys. Cornerstone states it evaluates family satisfaction using the DEYTA SYSTEM, an organization that has designated a survey for hospices, captures the data, analyzes and reports the results comparing hospices nationally. Agency records indicate that for the past 36 months the applicant had two confirmed complaints in patient care and untrained/unqualified staff.

Odyssey Healthcare of Marion County, Inc. (CON #10019) states that its management affiliate, Odyssey HealthCare, Inc., has a strong history of providing quality care and is one of the largest providers of hospice care in the nation. The applicant states it has 100 Medicare-certified hospice programs in 29 states, with an average daily census of over 12,000 patients. Within Florida, Odyssey has two licensed, Medicare and Medicaid certified hospice programs. The applicant provides a description of Odyssey’s quality of care which includes: governing body/scope of services policies, management of information policies, continuous quality improvement program, infection and exposure control program, education policies, assessment policies, patient and inpatient services policies, bereavement policies, admission and patient/family rights policies, discharge policies and access to care policies. In the past three years Odyssey has had one confirmed administrative complaint.

VITAS Healthcare Corporation of Florida (CON #10020) states that it is one of the oldest and largest Florida hospices and has been in operation for nearly 30 years. VITAS also states that it has a daily census of 2,900 patients and around 12,200 patients annually. The applicant states it has in excess of 1,000 nurses, and encourages these nurses through training, compensation incentives and support to become board-certified in hospice and palliative care. VHCF states it conducts a continuing, comprehensive, integrated assessment of the


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quality and appropriateness of care provided, including inpatient care, home care and care provided under arrangement. The applicant states the objectives of its quality improvement program are: to identify patient care quality areas for improvement, to ensure that care provided is appropriate to patient needs, and to revise procedures as necessary. The applicant details its quality of care characteristics20. The applicant has had four confirmed complaints in the last three years ending July 23, 2008. VITAS has seven hospice programs throughout the State of Florida in Districts 11, 10, Subdistricts 9C, 7C, 7B, 7A, and 4B. The confirmed complaints were in medical records/charting, inappropriate discharge, inappropriate residents/patients, and, patient care.

HPH-Haven Alliance, Inc. (CON #10021) is a newly formed entity and as such has no operating history. However, Alliance’s co-sponsors, Hernando-Pasco Hospice, Inc., (HPH) and North Central Florida Hospice, Inc. d/b/a Haven Hospice (Haven) each have a long history of providing hospice care to a number of communities throughout North Florida. Both HPH and Haven are 501 (c) (3) community-based, not-for-profit organizations, and are members of, and quality partners with, the National Hospice and Palliative Care Organization and Florida Hospices and Palliative Care, Inc. Haven is accredited by the Community Health Accreditation Program (CHAP), and is accredited as a Jewish hospice by the National Institute for Jewish Hospice (NIJH)21. Haven has also been awarded the Circle of Life award for 2008 by the American Hospital Association22. The Alliance has decided that Haven’s approved quality improvement plan in place, and a complete and thorough set of policies and procedures to guide care delivery will be the models used for its proposed hospice in Service Area 3B23. Agency records indicate that for the past 36 months the applicant’s co-sponsors had one confirmed resident/patient rights complaint.

20 Quality of Care characteristics can be found on pages 110-116. 21 NIJH is a non-profit organization established in 1985 to alleviate suffering in serious & terminal illness which recently established an accreditation program providing on site training for care of the Jewish terminally ill in hospice, geriatric centers and hospitals in the U.S. Forty of these providers have been accredited per the NIJH website at www.nijh.org/. 22 http://www.aha.org/aha/news-center/awards/circle-of-life/index.html 23 A copy of the current Haven quality improvement plan is provided in Tab 6, CON Application #10022.


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Voyager HospiceCare, Inc. (CON #10022) states it has in place an extensive program for assuring staff are well qualified to serve hospice patients and their families and that procedures are in place to assure that care is consistent and of the highest standards. Voyager states it is committed to providing quality of care at the highest level to terminally ill patients and their families residing in Marion County. Voyager provided the following examples of ways it provides quality services and activities: program integrity process, annual agency evaluation compliance reports, commitment to compliance activities, staff education and certifications, clinical excellence through extensive training programs, new employee orientation, ELNEC training and certification, annual compliance training, disease specific training, annual in-service education programs, continuing education/training hours requirements, 24-hour triage nurse, and patient, family, and referrer satisfaction surveys. Voyager has no operating history within the state of Florida. Voyager was founded in 2003 and provides hospice care in 24 locations in three states: Texas, Kansas, and Missouri.

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(4), Florida Statutes.

Adventa Hospice Services of Florida, Inc. (CON #10016): The audited financial statements of the applicant were reviewed to assess the financial position as of the balance sheet date and the financial strength of its operations for the period presented. Adventa Hospice Services of Florida, Inc. is a Florida for-profit corporation, incorporated in November 2007. As of December 31, 2007, the applicant had $10,000 in assets and liabilities, with no operating results. The applicant provided audited financial statements of its ultimate parent company, Amedisys, Inc. (parent), a for-profit corporation, for the periods ending December 31, 2007 and 2006. 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 1.6 indicates current assets are more than one and a half times the current obligations, an adequate position. The working capital of $62.7 million is a measure of excess liquidity that


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could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.9 indicates that cash flow is slightly less than current obligations. This is well above average and a good position. Overall, the applicant has a good short-term position. (See Table below). Long-Term Position: The ratio of long-term debt to net assets of 0.1 indicates the applicant has sufficient equity to have access to capital. The most recent year had $96.5 million in operating income, and an increase in net assets of $83.8 million. Overall, the applicant has an acceptable long-term position. (See Table below). It should be noted the applicant engaged in several acquisitions after year end which were funded primarily with debt.

Amedisys, Inc.

12/31/2007 12/31/2006

Current Assets (CA) $164,513,000 $179,205,000

Cash and Current Investment $56,190,000 $84,221,000

Assets Restricted for Capital Projects $0 $4,797,000

Non-Current Assets $422,598,000 $284,551,000

Total Assets (TA) $587,111,000 $463,756,000

Current Liabilities (CL) $101,736,000 $81,918,000

Total Liabilities $139,291,000 $99,749,000

Net Assets (NA) $446,971,000 $364,007,000

Total Revenues (TR) $697,934,000 $541,148,000

Interest Expense (IE) $835,000 $4,907,000

Operating Income (OI) $96,562,000 $65,656,000

Cash Flow from Operations (CFO) $93,085,000 $43,080,000

Working Capital $62,777,000 $97,287,000

12/31/2007 12/31/2006

Current Ratio (CA/CL) 1.6 2.2

Cash Flow to Current Liabilities (CFO/CL) 0.9 0.5

Long-Term Debt to Net Assets (TL-CL/NA) 0.1 0.0

Times Interest Earned (OI+IE/IE) 116.6 14.4

Net Assets to Total Assets (NA/TA) 76.1% 78.5%

Operating Margin (OI/TR) 13.8% 12.1%

Return on Assets (OI/TA) 16.4% 14.2%

Operating Cash Flow to Assets (CFO/TA) 15.9% 9.3%


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Capital Requirements: Schedule 2 listed capital projects totaling $285,141. This total includes only the project costs for the proposed hospice. The applicant is projecting a year one operating loss of $83,012. The applicant will have to fund the year one operating loss until profitability can be reached. Staffing:

Schedule 6A indicates for year one ending June 30, 2009, the applicant forecasts 19.92 FTEs as follows: 1.00 FTE director of operations, 1.00 FTE business office manager, 1.00 FTE business office support, 1.00 FTE account executive, 1.00 FTE community education, 4.25 FTEs nursing, 0.24 FTE dietary, 1.70 FTEs MSW, 4.25 FTEs hospice assistant, 1.06 chaplain, 0.50 bereavement coordinator, 0.50 FTE volunteer coordinator, 1.00 FTE intake coordinator, 0.12 FTE medical director. In the second year of operations ending June 30, 2010, the applicant forecasts 26.00 FTEs as follows: 1.00 FTE director of operations, 1.00 FTE business office manager, 1.00 FTE business office support, 1.00 FTE account executive, 1.00 FTE community education, 6.20 FTEs nursing, 0.25 FTE dietary, 2.48 FTEs MSW, 6.20 FTEs hospice assistant, 1.55 chaplain, 0.50 bereavement coordinator, 1.00 FTE volunteer coordinator, 1.00 FTE intake coordinator, 0.12 FTE medical director. The applicant states that retention of staff is insured through offering of benefits to full-time employees as well as through the company’s core beliefs. The applicant has also implemented a “hire to retire” program where incentive programs for all staff integrate clinical outcomes to financial performance. Available Capital:

As mentioned above, the capital budget requirements are $285,141, all for the proposed hospice. Funding for this project will be provided by the parent. Amedisys has working capital of $62.7 million and $96.5 million in operating income, and in addition, cash flow from operations was $93.0 million. The project would represent .4 percent of Amedisys’ working capital and .3 percent of operating cash flows. Conclusion:

Based on the parent corporation’s financial position and the relatively small size of the project, funding for this project and all capital projects should be available as needed.


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HCR Manor Care Services of Florida II, Inc. (CON #10017): HCR Manor Care Services of Florida II, Inc., a development stage company, is a Florida for-profit corporation, incorporated in March 2008. As of April 30, 2008 the applicant had no assets and $350 in liabilities, with negative $350 in operating results. The applicant provided audited financial statements of its ultimate parent company, HCR Manor Care, Inc. (parent), a for-profit corporation, for the periods ending December 21, 2007 and December 31, 2006. The December 21, 2007, year end is the result of the parent’s merger and conversion to a privately held company. 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 0.4 indicates current assets are less than half of the current obligations, a weak position. The working capital of negative $1 billion is in part a result of Manor Care, Inc. settling existing long-term debt as part of being purchased and held as a private company. Most of the purchase price consists of debt financing. The ratio of cash flow to current liabilities of 0.2 is well below average and weak position. Overall, the parent has a weak short-term position. (See Table below). Long-Term Position: The ratio of long-term debt to net assets of 1.9 indicates the parent is highly leveraged and may have difficulty obtaining future debt as necessary. The most recent year had $16.9 million in operating income, which resulted in a 0.4 percent operating margin. Overall, the parent has a weak long-term position. (See Table below). It should be noted that the parent was purchased and held as a private company. Based on information filed through the change of ownership process, the purchase was funded primarily with debt. The level of debt acquired by Manor Care is a significant increase and raises concerns about Manor Care’s long-term ability to service the debt.


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Manor Care, Inc.

12/21/2007 12/31/2006



Assets Restricted for Capital Projects $0 $0

Non-Current Assets $1,694,345,000 $1,779,283,000

Total Assets (TA) $2,538,402,000 $2,398,477,000

Current Liabilities (CL) $1,908,665,000 $523,629,000

Total Liabilities $2,321,102,000 $1,825,284,000

Net Assets (NA) $217,300,000 $573,193,000

Total Revenues (TR) $3,770,458,000 $3,613,185,000

Interest Expense (IE) $32,218,000 $31,513,000



Working Capital ($1,064,608,000) $95,565,000

12/21/2007 12/31/2006









Capital Requirements: Schedule 2 listed capital projects totaling $389,262. The applicant is projecting a year one operating loss of $437,400. The applicant will have to fund the year one operating loss until profitability can be reached. Staffing: Schedule 6A indicates for year one ending June 30, 2010 the applicant forecasts a total of 14.8 FTEs as follows: 1.00 FTE administrator, 1.00 FTE community educator, 1.00 director of professional services, 0.25 FTE patient care coordinator, 1.00 FTE chaplain, 1.20 FTEs medical social worker, 1.00 FTE office manager, 1.00 FTE bereavement coordinator, 0.05 FTE medical director, 0.25 FTE continuous care staff, 1.00 FTE team coordinator, 1.00 FTE admission coordinator, 1.50 FTEs


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RNs, 2.50 FTEs HHAs, 1.00 FTE volunteer coordinator, and 0.05 FTE dietician. For year two ending June 30, 2011, the applicant forecasts a total of 23.96 FTEs as follows: 1.00 FTE administrator, 1.00 FTE community educator, 1.00 FTE director of professional services, 1.00 FTE patient care coordinator, 1.50 FTE chaplain, 2.49 FTEs medical social worker, 2.00 FTEs office manager, 1.00 FTE bereavement coordinator, 0.10 FTE medical director, 0.41 FTE continuous care staff, 1.00 FTE team coordinator, 1.00 FTE admissions coordinator, 4.18 FTEs RNs, 5.18 FTEs HHAs, 1.00 FTE volunteer coordinator, 0.10 FTE dietician. The applicant states it has established a recruitment strategy and guidelines that work well in recruitment endeavors. Heartland states it benefits from a continued investment in hiring, training, and retaining quality caregivers. HCR Manor Care offers nursing assistants hospice certification and encourages them to seek certification. In addition, Heartland states it commits to provide up to $10,000 annually for tuition reimbursement for employees to continue education in hospice or end-of-life-care. This includes tuition reimbursement for Heartland hospice staff to obtain certified hospice palliative nurse certification.

Available Capital:

As mentioned above, the capital budget requirements are $389,262, of which $364,262 is for the proposed hospice. Funding for this project will be provided by the parent company’s operating cash flow. Manor Care, Inc. reported cash flow from operations of $380.6 million. It is unclear how much of the parent’s future cash flow will be needed to fund the debt acquired in the merger. Conclusion:

Based on the relatively small size of the project, funding for this project should be available as needed. However, the long-term financial position of the parent could have a negative impact on the applicant’s operations going forward. Hospice of Lake & Sumter, Inc. (CON #10018): The applicant provided audited financial statements for the periods ending September 30, 2007 and September 30, 2006. 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.


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Short-Term Position: The Applicant’s current ratio of 1.2 indicates current assets are slightly more than the current obligations, an adequate position. The working capital of $1.5 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.7 is slightly above average and an adequate position. Overall, the applicant has an adequate short-term position. (See Table below). Long-Term Position: The ratio of long-term debt to net assets of 0.0 indicates the Applicant has no long-term debt, a good position. The most recent year had $3.1 million in operating income, which resulted in a 6.4 percent operating margin. The ratio of cash flow to assets of 18.0 percent is over twice the average and a good position. Overall, the Applicant has a good long-term position. (See Table below).

CON 10018 – Hospice of Lake & Sumter, Inc.

9/30/2007 9/30/2006



Interest in Foundation $4,443,125 $5,832,134

Total Assets (TA) $23,542,601 $19,826,346



Net Assets (NA) $17,048,629 $15,373,921


Interest Expense (IE) $0 $0

Operating Income (OI) $3,063,717 $568,513


Working Capital $1,483,490 $1,267,867

9/30/2007 9/30/2006




Times Interest Earned (OI+IE/IE) N/A N/A






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Capital Requirements: Schedule 2 listed capital projects totaling $3,225,384. The applicant is projecting a year one operating loss of $369,140. The applicant will have to fund the year one operating loss until profitability can be reached. Staffing: Schedule 6A indicates for year one ending December 31, 2009 the applicant forecasts a total of 23.20 FTEs as follows: administration 5.00 FTEs, physicians 0.50 FTE, nursing 14.10 FTEs, dietary 0.10 FTE, social services 3.50 FTEs. Year two ending December 31, 2010, the applicant forecasts a total of 41.90 FTEs as follows: administration 5.00 FTEs, physicians 1.00 FTE, nursing 28.5 FTEs, dietary 0.10 FTE, and social services 7.30 FTEs.

Recruitment and retention of staff are areas of business that Cornerstone states it values highly. Cornerstone asserts it spends a minimum of $128,000 on staff support and education annually. Such activities as team retreats, support groups, parties, gas cards, lunches, conferences and in-services assist staff to remain loyal and committed to Cornerstone. Additionally, Cornerstone states it recognizes the importance of offering flexible work schedules and alternative work environments. This attention to staff needs had meant a very low staff turn-over rate. Cornerstone also conducts annual compensation and benefit surveys to compare itself with local hospices and health care institutions. Cornerstone states it adjusts compensation to stay competitive within the market and retain staff.

Available Capital: As mentioned above, the capital budget requirements are $3,225,384, of which $200,347 is for the proposed hospice. The applicant reported cash flow from operations of $4.2 million, interest in Foundation of $4.4 million, and working capital of $1.5 million. The Hospice Foundation of Lake & Sumter, Inc. (the Foundation) is a separate not-for-profit corporation whose purpose is raising funds to support the projects and programs of the Hospice. Conclusion:

Based on the applicant’s financial position and the relatively small size of the project, funding for this project and all capital projects should be available as needed.


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Odyssey Healthcare of Marion County, Inc. (CON #10019): Odyssey Healthcare of Marion County, Inc. (Applicant) is a Florida for-profit corporation, incorporated in 2005. As of April 30, 2008 the applicant had no assets and $315,104 in liabilities, with negative $315,104 in operating results. The applicant provided audited financial statements of its ultimate parent company, Odyssey HealthCare, Inc., (parent), a for-profit corporation, for the periods ending December 31, 2007 and 2006. 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 2.0 indicates current assets are twice the current obligations, an adequate position. The working capital of $72.5 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.2 is well below average and a weak position. Overall, the parent has an adequate short-term position. (See Table below). Long-Term Position: The ratio of long-term debt to net assets of 0.1 indicates the parent has sufficient equity to have access to capital. The most recent year had $20.5 million in operating income, which resulted in a 5.1 percent operating margin. Overall, the parent has a good long-term position. (See Table below).


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Odyssey HealthCare, Inc.

12/31/2007 12/31/2006



Assets Restricted for Capital Projects $0 $0

Total Assets (TA) $275,209,000 $269,986,000



Net Assets (NA) $182,837,000 $179,596,000


Interest Expense (IE) $208,000 $187,000



Working Capital $72,493,000 $70,555,000

12/31/2007 12/31/2006









Capital Requirements: Schedule 2 listed capital projects totaling $1,110,111. The applicant is projecting a year one operating loss of $472,651. The applicant will have to fund the year one operating loss until profitability can be reached. Staffing: Schedule 6A indicates for year one ending June 30, 2010 the applicant forecasts a total of 16.70 FTEs as follows: administration 9.00 FTEs, physicians 0.10 FTE, nursing 5.20 FTEs, dietary 0.30 FTE, and social services 0.60 FTE. For the second year of operations ending June 30, 2011, the applicant forecasts a total of 31.80 FTEs as follows: administration 10.50 FTEs, physicians 0.10 FTE, nursing 15.40 FTEs, ancillary 3.90 FTEs, dietary 0.30 FTE, and social services 1.60 FTEs.


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Odyssey states it is confident in its ability to fill the necessary staff positions because of its effective recruitment and retention policies and programs. In addition to the traditional recruitment techniques of newsprint and website postings, Odyssey states it works with headhunters, and provides employee referral bonuses. With regard to retention, Odyssey states it offers very competitive benefits, flexible work schedules, and competitive pay. Odyssey’s RN certification program provides reimbursement for continuing education and bonus awards based on the certification level achieved. Available Capital: As mentioned above, the capital budget requirements are $1,110,111, of which $584,998 is for the proposed hospice. The parent reported cash flow from operations of $16.9 million. The parent has working capital of $72.5 million and $20.5 million in operating income. The project would represent 0.8 percent of the parent’s working capital and 3.5 percent of operating cash flows.

Conclusion: Based on the parent’s financial position and the relatively small size of the project, funding for this project and all capital projects should be available as needed. VITAS Healthcare Corporation of Florida (CON #10020): VITAS Healthcare Corporation of Florida (VHCF) is a Florida corporation, an indirect wholly owned subsidiary of Chemed Corporation (parent), a publicly held Delaware corporation. The applicant states it intends to fund this project from its own operating cash flows. In addition, the applicant also provided a funding letter from its parent corporation stating that if for any reason the VHCF did not have the necessary funds for the project or its working capital needs, the parent would supply such funding. In support of its own, and its parents ability to fund the project, the applicant provided audited financial statements of both itself, and its parent for the periods ending December 31, 2007 and 2006 for review. These financial statements were analyzed for the purpose of evaluating both the applicant’s and its parent’s ability to provide the capital and operational funding necessary to implement the project. While the Form 10-K information provided for the parent company contained only the financial statements, we were able to view complete information, including notes to the financial statements, on the Securities and Exchange Commission’s web site.


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Short-Term Position: Applicant: The applicant’s current ratio of 1.7 is slightly below average and indicates current assets are just over more than one and a half times current liabilities, an adequate position. The ratio of cash flows to current liabilities of 1.4 is well above average and a strong position. The working capital (current assets less current liabilities) of $9.4 million is a measure of excess liquidity that could be used to fund capital projects. Overall, the applicant has an adequate short-term position. (See Table below). Parent: The parent’s current ratio of 0.9 is well below average and indicates current assets are slightly less than current liabilities, a moderately weak position. The ratio of cash flows to current liabilities of 0.7 is average and a good position. The parent company’s working capital is negative $13.4 million indicating it has no excess liquidity to fund additional capital projects. Overall, the parent has a moderately weak short-term position. (See Table below). Long-Term Position: Applicant: The long-term debt to equity ratio of 0.7 is slightly above average and indicates that the applicant has a moderate proportion of long-term debt, an adequate position. The cash flow to assets ratio of 14.2 percent is well above average and a strong position. For the period ended December 31, 2007, the applicant had excess revenues over expenses of $32.9 million, which resulted in a margin of 15.9 percent. Overall, the applicant has a good long-term operating position. Parent: The long-term debt to equity ratio of 0.7 indicates that the parent has a slightly above average proportion of long-term debt, an adequate position. The cash flow to assets ratio of 12.9 percent is above average and a good position. For the period ended December 31, 2007, the company had excess revenues over expenses of $122.8 million, which resulted in a margin of 11.2 percent. Overall, the parent has a good long-term operating position.


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CON #10020 -- December 31, 2007 Audited Financial Statements

Applicant Parent


Cash and Current Investment $2,798 $4,988,000

Due To/From Parent ($54,464,582) N/A

Non-Current Assets $118,287,180 $632,908,000

Total Assets (TA) $141,636,708 $772,313,000


Total Liabilities (TL) $68,425,052 $407,964,000

Net Assets (NA) $73,211,656 $364,349,000

Total Revenues (TR) $207,606,546 $1,100,058,000

Interest Expense (IE) $0 $11,244,000



Working Capital $9,389,058 ($13,427,000)

FINANCIAL RATIOS

Applicant Parent




Times Interest Earned (OI+IE/IE) N/A 11.9





Capital Requirements: The company indicated on Schedule 2 of the application projects or expenditures applied for, pending approval, or planned totaling $5,410,064 including the project subject to this CON application. In addition to the total cost projected for the project of $327,188, the applicant anticipates a first-year incremental operating loss for the project of $472,500. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2.


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Finally, the applicant offered a condition that requires it to make a charitable contribution of $50,000 to the American Cancer Society at the time of certification for purposes of educating the community on advance directives. Staffing: Schedule 6A indicates for year one ending December 31, 2009 the applicant forecasts a total of 16.66 FTEs as follows: general manager 1.00 FTE, business manager 0.58 FTE, hospice representative 2.00 FTEs, admissions 0.18 FTE, pc secretary 0.58 FTE, physician 0.32 FTE, team director 1.00 FTE, RNs 2.25 FTEs, LPNs 1.83 FTEs, nurses aides 3.92 FTEs, on-call representative 0.50 FTE, social worker 1.00 FTE, volunteer/bereavement manager 0.50 FTE and chaplain 1.00 FTE. Year two ending December 31, 2010 the applicant forecasts a total of 41.25 FTEs as follows: general manager 1.00 FTE, business manager 1.00 FTE, hospice representative 2.54 FTEs, admissions 1.13 FTE, pc secretary 1.38 FTE, receptionist 0.92 FTE, physician 0.85 FTE, team director 2.08 FTE, RNs 5.62 FTEs, LPNs 6.78 FTEs, nurses aides 13.70 FTEs, on-call representative 1.63 FTE, social worker 1.71 FTE, volunteer/bereavement manager 1.00 FTE and chaplain 1.04 FTE. Dietary is a core service and cannot be provided for through contract services. The applicant does not have an FTE for dietary services on Schedule 6A24. Available Capital: As mentioned above, the capital budget requirements for the proposed project are $327,188. The applicant states that the funding for this project will come from its own operating cash flow, with its parent company committing any funding shortfall up to the amount of the project. The applicant has working capital of $9.4 million and $32.9 million in operating income, and in addition, cash flow from operations was $20.1 million. The project would represent 3.5 percent of VITAS’s working capital and 1.6 percent of operating cash flows. Conclusion: Based on the liquidity of both the applicant and its parent corporation, funding for this project should be available as needed.

24Section 400.609, Florida Statutes.


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HPH-Haven Alliance, Inc. (CON #10021): The audited financial statements of the applicant were reviewed to assess the financial position as of the balance sheet date and the financial strength of its operations for the period presented. The applicant is a development stage company formed on May 2, 2008, as a not-for-profit corporation pursuant to Chapter 617, Florida Statutes, and reports net assets of $115,666 as of May 31, 2008. The applicant is comprised of two corporate sponsors, Hernando-Pasco Hospice, Inc. (Hernando-Pasco) and North Central Florida Hospice, Inc. d/b/a Haven Hospice (Haven), both of which are also Florida not-for-profit corporations. Both Hernando-Pasco and Haven (Sponsors) submitted commitment letters indicating each would provide up to $500,000 ($1,000,000 combined) to support the total project costs, as well as any necessary working capital and other funding needed to cover operating losses during the start-up phase of new hospice operations. As a development stage company, the applicant will likely have to rely on the financial position of the sponsor companies to obtain any debt financing. The applicant submitted the audited financial statements of Hernando-Pasco for the periods ending September 30, 2006 and 2007, and December 31, 2006 and 2007 for Haven. The sponsors’ audited financial statements were analyzed for the purpose of evaluating their ability to acquire and provide the capital and operational funding necessary to implement the project. Short-Term Position - Hernando-Pasco: Note: Hernando-Pasco’s audit did not clearly identify short or long-term

assets and liabilities. The following analysis represents our best estimate

of our short and long-term position of Hernando-Pasco based on the

information provided in the audit report. The current ratio of 4.5 is well above average and indicates current assets are four and a half times current liabilities, a strong position. The ratio of cash flows to current liabilities of 1.6 is well above average, a strong position. The working capital (current assets less current liabilities) of $16.1 million is a measure of excess liquidity that could be used to fund capital projects. Overall, Hernando-Pasco has a strong short-term position. (See Table below).


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Short-Term Position - Haven: The current ratio of 2.0 is average and indicates current assets are two times current liabilities, a good position. The ratio of cash flows to current liabilities of 0.8 is above average and a good position. The working capital (current assets less current liabilities) of $8.7 million is a measure of excess liquidity that could be used to fund capital projects. Overall, Haven has a good short-term position. (See Table below). Long-Term Position - Hernando-Pasco: The ratio of long-term debt to net assets of 0.4 indicates long-term debt is less than equity. This is well below average and a good position. The ratio of cash flow to assets of 19.9 percent is well above average and a strong position. The most recent year had revenue in excess of expenses of $4.2 million, which resulted in a margin of 7.0 percent. Overall, Hernando-Pasco has a good long-term position. (See Table below). Long-Term Position - Haven: For the period ending December 31, 2007, Haven reported relatively no long-term debt, down from $3.3 million for the previous year – a strong position. The ratio of cash flow to assets of 17.6 percent is well above average and a strong position. The most recent year had $2.9 million of revenues in excess of expenses, which resulted in a margin of 6.3 percent. Overall, Haven has a strong long-term position. (See Table).


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CON #10021 – Alliance Sponsors’ Audited Financial Statements

Hernando-Pasco Haven

September 30, December 31,

2007 2007



Assets Limited as to Use N/A $1,483,788

Total Assets (TA) $36,082,000 $38,232,860



Net Assets (NA) $22,467,000 $29,624,783


Interest Expense (IE) $487,000 $258,052



Working Capital $16,111,000 $8,684,682

FINANCIAL RATIOS

Hernando-Pasco Haven










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Capital Requirements: The company indicated on Schedule 2 of the application projects or expenditures applied for, pending approval, or planned totaling $517,400 including the project subject to this CON application. In addition to the total cost projected for the project of $462,400, the applicant anticipates a first-year operating loss for the project of $446,573. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2. Staffing: Schedule 6A indicates for year one ending June 30, 2010 the applicant forecasts a total of 17.00 FTEs as follows: administration 7.00 FTEs, physicians 0.25 FTE, nursing 5.50 FTEs, ancillary 1.00 FTE, dietary 0.25 FTE and social services 3.00 FTE. For year two ending June 30, 2011, the applicant forecasts a total of 22.75 FTEs as follows: admissions 7.00 FTEs, physicians 0.50 FTE, nursing 9.00 FTEs, ancillary 1.00 FTE, dietary 0.25 FTE, and social services 5.00 FTEs. The applicant states that both co-sponsors have been effective in recruiting high quality staff to meet its personnel needs, and each has appropriate recruitment and retention policies, procedures, approaches and techniques in place. The applicant states that upon receipt of CON it will recruit and hire an executive director whose first task will be to identify best practices of sponsors regarding staff recruitment and retention and to develop and implement a recruitment plan that will be used to meet the staffing and volunteer needs of the proposed program. Available Capital: The applicant indicates that funding for this project will come from the two sponsoring companies. As previously mentioned, both sponsoring companies provided letters of commitment of up to $500,000 each to fund the total project costs, as well as any necessary working capital and other funding needed to cover operating losses during the startup phase of new hospice operations. The audited financial statements of the members show a combined cash and current investment balance of $28.6 million with $24.8 million in working capital. Conclusion: Based on the financial strength of its corporate sponsors, the applicant should have access to funding for this project and all capital projects and working capital as needed.


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Voyager HospiceCare, Inc. (CON #10022): The applicant provided its audited financial statements for the periods ending December 31, 2007 and 2006 for review. These financial statements were analyzed for the purpose of evaluating applicant’s ability to provide the capital and operational funding necessary to implement the project. Short-Term Position: The applicant’s current ratio of 0.8 is well below average and indicates current assets are slightly less than current liabilities, a weak position. The ratio of cash flows to current liabilities of 0.6 slightly below average and an adequate position. The working capital (current assets less current liabilities) of negative $1.9 million indicates the applicant has no excess liquidity that could be used to fund capital projects. Overall, the applicant has a weak short-term position. (See Table below). Long-Term Position: The applicant’s long-term debt to equity ratio of negative 14.2 is well below average and indicates the applicant’s liabilities exceed assets. This is a weak position and may impair the applicant’s ability to acquire future long-term debt at reasonable rates. The cash flow to assets ratio of 14.6 percent is well above average and a strong position. The most recent year had excess revenues over expenses of $4.6 million, which resulted in an operating margin of 5.6 percent. Overall, the applicant has a moderately weak long-term position. (See Table below).


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CON #10022 -- Voyager HospiceCare, Inc.

12/31/2007 12/31/2006


Cash and Current Investment $2,553,736 $660,629

Goodwill $32,571,518 $32,571,518

Total Assets (TA) $44,155,220 $45,270,189



Net Assets (NA) ($2,516,027) ($2,926,560)


Interest Expense (IE) $1,670,930 $3,454,935



Working Capital ($1,881,914) ($4,357,816)

FINANCIAL RATIOS

12/31/2007 12/31/2006



Long-Term Debt to Net Assets (TL-CL/NA) -14.2 -11.6


Net Assets to Total Assets (NA/TA) -5.7% -6.5%




Capital Requirements: The company indicated on Schedule 2 of the application projects or expenditures applied for, pending approval, or planned totaling $16,237,558 including the project subject to this CON application. In addition to the total cost projected for the project of $237,558, the applicant anticipates a first-year incremental operating loss for the project of $498,635. The applicant would have to fund this operating loss in addition to the capital projects listed on Schedule 2. Staffing: Schedule 6A indicates for year one ending June 30, 2010 the applicant forecasts a total of 17.00 FTEs as follows: administration 5.50 FTEs, physicians 0.30 FTE, nursing 5.40 FTEs, ancillary 0.04 FTE, social


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services 1.50 FTEs, and dietary 0.03 FTE. Year two ending June 30, 2011, the applicant forecasts a total of 19.31 FTEs as follows: administration 6.33 FTEs, physicians 0.30 FTE, nursing 10.98 FTEs, ancillary 0.11 FTE, dietary 0.09 FTE, and social services 1.50 FTEs. Voyager states it does not foresee any challenges with recruitment or retention of the required staff and anticipates utilizing senior management to provide oversight and support for the proposed hospice program. Available Capital: As mentioned above, the capital budget requirements for the proposed project are $237,558. The applicant states that it will provide the funding for this project. With negative working capital and equity, the applicant would have to rely on future cash flows and its $8 million line of credit to fund this project. The applicant has working capital of negative $1.9 million and $4.6 million in operating income. In addition, the project would represent 3.7 percent of the applicant’s 2007 operating cash flows of $6.4 million. In its discussion of total capital projects reported on Schedule 2, the applicant stated the remaining $16 million in projects not related to the subject CON will be financed from third-party sources as necessary and will not impact the ability to fund the project subject to this CON. The applicant further stated, “Voyager has the necessary financial backing for acquisitions from its majority owner, Apax Partners [a private equity investment group], a leading investment firm with numerous highly successful partnerships with healthcare organizations.” However, the applicant did not provide any commitment or other letter of support from Apax Partners in support of this assertion, or any audited financial statements for Apax Partners. In addition, notes to the applicant’s financial statements indicates that the applicant has entered into a management agreement with Apax Partners, and that affiliates of Apax Partners, SKM Equity Fund III and SKM Investment Fund (jointly SKM) have made equity investments in Voyager HospiceCare Holdings, LLC, parent of the applicant. Conclusion: Based on the relatively small size of the project, funding should be available as needed. However, funding available for the entire capital budget is in question.


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d. What is the immediate and long-term financial feasibility of the

proposal? ss. 408.035 (6), Florida Statutes. The following applies to all applicants. Schedule 7 of the application indicates that the services to be provided are routine home care, continuous home care, inpatient respite, and general inpatient. The Department of Health and Human Services sets rates for routine home care, continuous home care, inpatient respite care, and general inpatient care. The Federal rates were calculated for Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through the appropriate period for each applicant. The average price adjustment factor used was three percent per year based on the new CMS market Basket Price Index as published in the 1st Quarter 2008 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 for each applicant below.

Adventa Hospice Services of Florida, Inc. (CON #10016): The payer types identified in the application as a percentage to total patient days are: Medicare at 85.0 percent, Medicaid at 6.5 percent, self-pay/charity at 3.0 percent, and commercial insurance at 5.5 percent.

The Federal rates were calculated for Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through June 2010. The applicant’s projected gross revenue was -10.54 percent or $276,105 less than the calculated gross revenue. The applicant did not appear to use the correct Medicare prospective reimbursement rates. The rates the applicant used are lower than the 2008 Medicare Hospice rates. (See Table below).


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Payment Rate

Services Medicare Applicant

Routine Home Care $130.08 $125.24

Continuous Home Care $759.18 $730.91

Inpatient Respite $135.66 $130.61

General Inpatient $580.17 $558.57

Projected revenues appear to be overstated. This difference is material; however overstating revenues in a financial project is considered a conservative assumption and is therefore reasonable. The applicant projected a profit of $358,237 by the end the second year of operations. Overstating revenues in a financial project is considered a conservative assumption and is therefore reasonable. Conclusion:

This project appears to be financially feasible.

HOSPICE REVENUE TABLE

CON #10016 Adventa Hospice Services of Florida, Inc.

Wage Index for Marion County(0.9458)

Wage

Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $92.83 0.9458 $87.80 $42.28 $130.08

Continuous Home Care $541.81 0.9458 $512.44 $246.74 $759.18

Inpatient Respite $75.65 0.9458 $71.55 $64.11 $135.66

General Inpatient $384.71 0.9458 $363.86 $216.31 $580.17

Payment

Rate

Inflation Factor Year

Two

Inflation Adjusted Amount

Patient Days Year two,

Sept 30-2011

Calculated Gross

Revenue

Routine Home Care $130.08 1.052 $136.83 18,763 $2,567,281

Continuous Home Care $759.18 1.052 $798.57 96 $76,663

Inpatient Respite $135.66 1.052 $142.70 96 $13,699

General Inpatient $580.17 1.052 $610.27 390 $238,004

Total 19,345 $2,895,647

From Schedule 7 $2,619,541

Difference -$276,105

Percentage difference -10.54%


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HCR Manor Care Services of Florida II, Inc. (CON #10017): The payer types identified in the application as a percentage to total patient days are: Medicare at 89.5 percent, Medicaid at 6.2 percent, self-pay/charity at 2.0 percent, and commercial insurance at 2.3 percent. The Federal rates were calculated for Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through June 2011. The applicant offered 16 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 5.29 percent or $181,145 less than the calculated gross revenue. Our analysis was based on gross revenues. The applicant made contractual adjustments of $75,449 which account for the majority of the difference. The remaining difference is immaterial; therefore the revenue projections appear to be reasonable. The applicant projected an operating profit of $198,581 by the end the second year of operations. Conclusion:



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CON #10017 HCR Manor Care Services of Florida II, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate


Two



Sept 30-2011

Calculated Gross

Revenue





Total 22,685 $3,603,018




Hospice of Lake & Sumter, Inc. (CON #10018): The payer types identified in the application as a percentage to total patient days are: Medicare at 79.0 percent, Medicaid at 6.0 percent, commercial insurance at 4.0 percent, and other care at 11.0 percent. The Federal rates were calculated for Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through December 2010. The applicant’s projected gross revenue, less room and board revenue, was 2.12 percent or $97,881 less than the calculated gross revenue. Our analysis was based on gross revenues. The applicant made contractual adjustments of $69,128 which account for the majority of the difference. The remaining difference is immaterial; therefore the revenue projections appear to be reasonable. The applicant projected an operating profit of $257,929 by the end the second year of operations. Conclusion:



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CON #10018 Hospice of Lake & Sumter, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate


Two



Sept 30-2011

Calculated Gross

Revenue





Total 28,335 $4,706,387


Difference -$97,881


Odyssey Healthcare of Marion County, Inc. (CON #10019): The payer types identified in the application as a percentage to total patient days are: Medicare at 93.0 percent, Medicaid at 3.0 percent, commercial insurance at 1.0 percent, self-pay at 2.0 percent, and other managed care at 1.0 percent. The Federal rates were calculated for Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through June 2011. The applicant offered 21 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 0.61 percent or $20,258 less than the calculated gross revenue. This difference is considered immaterial; therefore the revenue projections appear to be reasonable.


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The applicant projected an operating profit of $192,135 by the end the second year of operations. Conclusion:



CON 10019 Odyssey HealthCare of Marion County, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate


Two



Sept 30-2011

Calculated Gross

Revenue





Total 20,328 $3,336,575


Difference -$20,258


VITAS Healthcare Corporation of Florida (CON #10020): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 86 percent, Medicaid at eight percent, charity at one percent, and commercial insurance at five percent. The Federal rates were calculated for the Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through December 2010.


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In calculating continuous care day revenue, the applicant made an assumption that results in a lower rate than the full continuous care rate. According to the notes to Schedule 7, based on their experience in providing this level of care, the applicant used an hourly rate to estimate revenues based on an average of 15 to 18 hours of care per patient day. Code of Federal Regulations 42CFR.302(e)(4), states that when a patient is under continuous care for eight or more hours but less than 24 hours in a day, the daily rate is converted to an hourly rate. In order to be consistent with the applicant’s method, the payment estimated for this level of service was calculated based on 16.5 hours per patient day (midpoint of the applicant’s assumed range) at an hourly rate that is 1/24th of the estimated daily rate for this level of service. The applicant’s projected gross revenue was 5.08 percent ($187,835) less than the calculated gross revenue. Understating revenue is a conservative assumption and therefore, considered reasonable. Operating profits from this project are expected to increase from a loss of $472,500 for year one to a profit of $5,285 for year two. The applicant offered 13 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. Conclusion:



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CON #10020 -- VITAS Healthcare Corporation of Florida


Wage


Adjusted Wage


Payment Rate


Continuous Home Care* $541.81 0.9458 $512.44 $246.74 $521.94



Payment

Rate

Inflation Factor

Year Two


Patient Days Year two, Dec. 31,

2010

Calculated Gross

Revenue


Continuous Home Care $521.94 1.067 $556.69 1,149 $639,636



Total 22,308 $3,883,547

From Schedule 7 (Gross) $3,695,712



*Rate adjusted to partial payment per applicant's assumptions (rate/24 hours x 16.5)

HPH-Haven Alliance, Inc. (CON #10021): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 85.7 percent, Medicaid at nine percent, self-pay at two percent, and commercial insurance at 3.3 percent. The Federal rates were calculated for the Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through June 2011. The applicant’s projected gross revenue was 3.03 percent ($97,377) less than the calculated gross revenue. Understating revenue is a conservative assumption and therefore, considered reasonable. In addition, the applicant noted that its projections take into account reductions in Medicare rates proposed by the Centers for Medicare and Medicaid Services for Federal Fiscal Year 2009. Operating profits from this project are expected to increase from an operating loss of $446,573 for year one to a profit of $245,712 for year two.


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Conclusion:



CON #10021 -- HPH--Haven Alliance, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate


Two



June 30-2011

Calculated Gross

Revenue




General Inpatient $580.17 1.080 $626.74 1,098 $688,165

Total 18,606 $3,313,097


Difference -$97,377


Voyager HospiceCare, Inc. (CON #10022): For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 88.4 percent, Medicaid at 4.5 percent, self-pay/charity at 1.5 percent, and commercial insurance at 5.6 percent. The Federal rates were calculated for the Marion County, Florida wage index for Medicare Hospice payments of 0.9458 and inflated through June 2011. In calculating continuous care day revenue, the applicant made an assumption that results in a lower rate than the full continuous care rate. According to the notes to Schedule 7, based on their experience in providing this level of care, the applicant used an hourly rate to estimate revenues based on an average two-thirds of the full, daily rate per patient day. Code of Federal Regulations 42CFR.302(e)(4), states that when a patient is under continuous care for eight or more hours but less than 24 hours in a day, the daily rate is converted to an hourly rate. In order


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to be consistent with the applicant’s method, the payment estimated for this level of service was calculated based on two-thirds the full, daily rate per patient day for this level of service. The applicant’s projected gross revenue was 3.2 percent, or $65,699, less than the calculated gross revenue. The majority of this difference is due to the applicant using a lower inflation rate (two percent) than the market basket rate. Understating revenue is a conservative assumption and therefore, considered reasonable. Operating profits from this project are expected to increase from a loss of $498,635 for year one to a profit of $120,686 for year two. Conclusion:



CON #10022 -- Voyager HospiceCare, Inc.


Wage


Adjusted Wage


Payment Rate


Continuous Home Care $541.81 0.9458 $512.44 $246.74 $506.12 *



Payment

Rate


Two



June 30-2011

Calculated Gross

Revenue





Total 14,595 $2,116,145


Difference -$65,699


* Rate adjusted to partial payment per applicant's assumptions (rate x 2/3)


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e. Will the proposed project foster competition to promote quality and

cost-effectiveness? ss. 408.035(7), Florida Statutes.

The following applies to all applicants. Each co-batched applicant is applying for a new hospice program to be located in Hospice Service Area 3B that currently has one existing hospice program. Therefore, each co-batched applicant is offering a new choice of provider in the hospice service area. All patient day projections are for year two of the projects.

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.

With the large majority of patient care being provided from fixed price government payer sources, a new hospice provider is not likely to have any discernable positive impact on competition to promote quality assurance or cost-effectiveness. However, with price not considered a major factor, competing hospice programs will likely focus on quality of service to remain competitive in the market. Therefore, although a new hospice provider is not likely to have any discernable positive impact on competition to promote cost-effectiveness, it is likely to have a positive impact on quality assurance. Adventa Hospice Services of Florida, Inc. (CON #10016): The applicant is projecting no patient days from managed care payers with 91.5 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). Commercial insurance is projected at 5.5 percent and self-pay/charity 3.0 percent of total patient days. HCR Manor Care Services of Florida II, Inc. (CON #10017): The applicant is projecting no patient days from managed care payers with 95.7 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). Commercial insurance is projected at 2.3 percent and self-pay/charity 2.0 percent of total patient days.


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Hospice of Lake & Sumter, Inc. (CON #10018): The applicant is projecting no patient days from managed care payers with 85.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). Commercial insurance is projected at 4.0 percent and other care 11.0 percent of total patient days. Odyssey Healthcare of Marion County, Inc. (CON #10019): The applicant is projecting one percent of patient days from managed care payers with 96.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). Commercial insurance is projected at 1.0 percent and self-pay/charity 2.0 percent of total patient days. VITAS Healthcare Corporation of Florida (CON #10020): The applicant is projecting five percent of patient days from commercial insurance payers with 94 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid), with charity care projected to account for the remaining one percent of total patient days. HPH-Haven Alliance, Inc. (CON #10021): The applicant is projecting 3.3 percent of patient days from commercial insurance payers with 94.7 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid), with self-pay/charity care projected to account for the remaining two percent of total patient days. Voyager HospiceCare, Inc. (CON #10022): The applicant is projecting 5.6 percent of patient days from commercial insurance payers with 92.9 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid), with charity care projected to account for the remaining 1.5 percent of total patient days.

f. Are the proposed costs and methods of construction reasonable? Do they comply with statutory and rule requirements? ss. 408.035(8), Florida Statutes.

Each of the co-batched applicants is requesting approval to establish a new hospice program rather than the development of a freestanding inpatient hospice facility. There are no construction costs and 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(9), Florida Statutes.


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Adventa Hospice Services of Florida, Inc. (CON #10016) states that it has a history of providing care to Medicaid patients and to charity and indigent patients. Schedule 7A shows $33,671 for charity care in year one, and $66,251 for charity care in year two. Charity care will account for three percent of total patient days for both year one and two. Adventa’s patient day Medicaid percentage is projected at 6.5 percent for years one and two.

HCR Manor Care Services of Florida, Inc. (CON #10017) and its parent company, HCR Manor Care, state they have a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. In 2007, the applicant states Heartland Hospice provided approximately $3,359,956 in charity care to its hospice patients. The applicant provides the following as its projected payer mix for Heartland for the first two years of operations. Schedule 7A shows $15,894 for self-pay/charity care in year one, and $34,216 for self-pay/charity care in year two. Notes to Schedule 7A indicate that charity care will account for one percent of total patient days. Schedule 7A shows Medicaid accounts for 6.2 percent of total patient days for years one and two. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) proposes services to Medicaid eligible persons and states that the projected mix of Medicaid patients for hospice to serve in 3B is six percent of total patients. Additionally, it is projected that the applicant will provide 17 percent of total care to the patients who are Medicaid recipients in skilled nursing facilities. In fiscal year 2007/2008, the applicant states it provided 4.6 percent of patient charges to Medicaid patients and 7.14 percent of patient charges in indigent care and uncompensated ancillary services. Schedule 7A shows Medicaid accounts for 5.6 percent of total patient days for years one and two. “Other” care is projected to be 10.9 percent for years one and two. Odyssey Healthcare of Marion County, Inc. (CON #10019) states it has consistently provided care to all patients in need of its services, including the traditionally underserved Medicaid/charity/indigent population. The applicant states that 60 percent of Odyssey HealthCare Inc.’s FY 2007 non-Medicare net revenue is Medicaid and 1.2 percent of services are provided to indigent/charity patients.


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Schedule 7A shows $31,846 for charity care in year one, and $99,011 for charity care in year two. Charity care is projected at two percent of total patient days for both years one and two. Odyssey’s patient day Medicaid percentage is projected at three percent for years one and two. VITAS Healthcare Corporation of Florida (CON #10020) states that it provides in excess of one percent of revenues in charity care. For fiscal year 2007, this amount exceeded $9.8 million having increased from $8.5 million in 2006 according to the applicant.

Schedule 7A shows $84,488 for charity care in year one, and $36,957 for charity care in year two. Charity care will account for 8.4 percent of total patient days for year one and one percent for year two. VITAS’s patient day Medicaid percentage is projected at 7.4 percent for year one and 8.0 percent for two.

HPH-Haven Alliance, Inc. (CON #10021) states that both its sponsors have a longstanding history of providing a substantial amount of health care and services to Medicaid patients and the medically indigent going beyond the Medicare Conditions of Participation or Florida licensure requirements for hospice providers. The applicant states that Hernando-Pasco Hospice provided 4.7 and 3.5 percent of patient days during 2006 and 2007 to Medicaid patients. Haven provided 6.9 percent and 8.6 percent of patient days during 2006 and 2007 to Medicaid patients, and 1.7 and 1.6 percent of patient days to indigent/charity care patients during the same period. According to Schedule 7A, self-pay will account for two percent of total patient days for year one and two respectively. Alliance’s patient day Medicaid percentage is projected at nine percent in years one and two respectively. Voyager HospiceCare, Inc. (CON #10022) states it has a history of providing hospice services to Medicaid patients and the medically indigent. In 2007, Voyager states its programs provided hospice services to 4,173 Medicare and 211 Medicaid patients representing 88.4 and 4.5 percent of total admissions respectively. Additionally, Voyager states it provided hospice services to 71 self-pay patients representing 1.5 percent of total admission in 2007. Schedule 7A shows $31,887 for charity care in year one, and $37,091 for charity care in year two. Self-pay/charity care will account for 3.95 percent of total patient days in year one and 1.5 percent in year two. Voyager’s patient day Medicaid percentage is projected at 4.49 percent in year one and 4.50 percent in year two.


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F. SUMMARY

A fixed need pool was published for a new hospice program in Hospice Service Area 3B, Marion County.

Adventa Hospice Services of Florida, Inc. (CON #10016) proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The project cost totals $285,141 with year one operating costs of $1,370,054 and year two costs of $2,195,053. The applicant proposes eight conditions to approval of the CON (see pages 6-8). HCR ManorCare Services of Florida II, Inc. (CON #10017) (Heartland Hospice) proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The applicant is proposing total project costs of $364,262 with year one operating cost of $2,313,438 and year two costs of $3,849,326. The applicant proposes 16 conditions to approval of the CON (see pages 9-12). Hospice of Lake & Sumter, Inc. Hospice (CON #10018) (Cornerstone Hospice) proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The proposed total project cost is $200,347 with year one operating costs of $1,871,786 and year two costs of $4,850,517. The applicant proposes 40 conditions to approval of the CON (see pages 12-15). Odyssey Healthcare of Marion County, Inc. (CON #10019) proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The proposed total project cost is $584,998 with year one operating costs of $1,574,550 and year two costs of $2,998,618. The applicant proposes 21 conditions to approval of the CON (see pages 15-19).

VITAS Healthcare Corporation of Florida (CON #10020) proposes the establishment of a new hospice program in Hospice Service Area 3B, Marion County. The proposed total project cost is $327,188 with total year one operating costs of $1,395,894 and year two costs of $3,653,469.


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The applicant proposes 13 conditions to approval of the CON (see pages 20-21). HPH-Haven Alliance, Inc. (CON #10021) proposes to establish a hospice program in Hospice Service Area 3B, Marion County. The proposed total project cost is $462,400 with total operating costs of $2,202,200 year one and year two costs of $3,735,924 The applicant proposes 25 conditions to approval of the CON (see pages 21-27). Voyager HospiceCare, Inc. (CON #10022) proposes to establish a hospice program in Hospice Service Area 3B, Marion County. The proposed total project cost is $237,558 with total operating costs of $1,139,183 year one and year two costs of $1,878,822. The applicant proposes 15 conditions to approval of the CON (see pages 27-30). Need/Access:

Each applicant is responding to published need for a new hospice program. Each applicant states that there is unmet need in Marion County, which ranged from access issues for patients age 65 and under, to chronically ill patient populations with Alzheimer’s disease. All seven co-batched applicants provided evidence that they have local support for their proposals to enter the service area. Local letters of support, highest to lowest volume: Alliance (126) Cornerstone (110), Heartland (49), Adventa (38), VITAS (9), Odyssey (6), and Voyager (3). These essentially state that they look forward to working with the applicant should the applicant be awarded a CON. All of the applicants, except VITAS, included letters from nursing homes indicating a willingness to contract for inpatient care and patient services. It is noted that many of the applicants’ letters were of the form letter variety. The Agency’s need methodology that resulted in published need for a new program in Marion County showed the projected number of admissions minus the current number of admissions for the July 2009 planning horizon as 430. Odyssey proposed the largest program to address this published need:


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Total Projected Admissions By Applicant

for Years One and Two CON # Applicant Year One Year Two

10016 Adventa 154 256

10017 Heartland 219 349

10018 Cornerstone 137 457

10019 Odyssey 285 405

10020 VITAS 193 418

10021 HPH-Haven 126 241

10022 Voyager 124 346 Source: CON Application #’s 10016-10022.

Quality of Care:

Each applicant offered evidence of its ability to provide quality care. Financial Feasibility/Availability of Funds:

Adventa Hospice Services of Florida, Inc. (CON #10016): Based on the parent corporation’s financial position and the relatively small size of the project, funding for this project and all capital projects should be available as needed. Overall the applicant’s short-term position is good and long-term position is acceptable.

HCR Manor Care Services of Florida, Inc. (CON #10017): Based on the relatively small size of the project, funding for this project should be available as needed. Overall the parent has a weak short-term position and a weak long-term position. Hospice of Lake & Sumter, Inc. (CON #10018): Based on the applicant’s financial position and the relatively small size of the project, funding for this project and all capital projects should be available as needed. Overall short-term position is adequate and long-term position is good. Odyssey Healthcare of Marion County, Inc. (CON #10019): Based on the parent’s financial position and the relatively small size of the project, funding for this project and all capital projects should be available as needed. Overall the parent has an adequate short-term position and a good long-term position. VITAS Healthcare Corporation of Florida (CON #10020): Based on the liquidity of both the applicant and its parent corporation, funding for this project should be available as needed. Overall, the applicant has an adequate short-term position and a moderately weak long-term position.


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HPH-Haven Alliance, Inc. (CON #10021): Based on the financial strength of its corporate sponsors, the applicant should have access to funding for this project and all capital projects and working capital as needed. HPH has a strong short-term position and a good long-term position. Haven has a good short-term position and a strong long-term position. Voyager HospiceCare, Inc. (CON #10022): Based on the relatively small size of the project, funding should be available as needed. However, funding available for the entire capital budget is in question. Overall, the applicant has a weak short-term position and a moderately weak long-term position. Medicaid/Charity Care:

Hospice Service Area 3B Projected Medicaid and Charity Care by Admissions

Year One and Year Two

CON

Year one Medicaid

Admissions

Year one Charity

Care Admissions

Year one

Total Admissions

Year two Medicaid

Admissions

Year two Charity

Care Admissions

Year two

Total Admissions

10016 10 4 154 17 6 256 10017* 219 349

10018 8 15 137 20 50 457 10019 9 6 285 12 8 405 10020 14 16 193 33 4 418

10021 9 5 126 16 9 241 10022 6 5 124 16 5 346

*CON 10017 HCR Manor Care does not provide admissions but projects Medicaid at 6.2 percent of year one and year two patient days and self-pay/charity care at two percent for both years one and two.

Adventa Hospice Services of Florida, Inc. (CON #10016) states that it has a history of providing care to Medicaid patients and to charity and indigent patients. Schedule 7A shows $33,671 for self-pay/charity care in year one, and $66,251 in year two. Self-pay/charity care will account for three percent of total patient days for both year one and two. Adventa’s patient day Medicaid percentage is projected at 6.5 percent for years one and two.

HCR Manor Care Services of Florida, Inc. (CON #10017) and its parent company, HCR Manor Care, state they have a history of providing health services to all patients that require hospice care, without regard to age, sex, race, ethnic group, diagnosis, or ability to pay. In 2007, the applicant states Heartland hospice provided approximately $3,359,956 in charity care to its hospice patients. Schedule 7A shows $15,894 for self-pay/charity care in year one, and $34,216 for self-pay/charity care in year two or two percent for both years. Notes to Schedule 7A indicate that charity care will account for one percent of total patient days.


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Schedule 7A shows Medicaid accounts for 6.2 percent of total patient days for year one and two. Hospice of Lake & Sumter, Inc. (CON #10018) (Cornerstone) proposes services to Medicaid eligible persons and states that the projected mix of Medicaid patients for hospice to serve in 3B is six percent of total patients. In fiscal year 2007/2008, the applicant states it provided 4.6 percent of patient charges to Medicaid patients and 7.14 percent of patient charges in indigent care and uncompensated ancillary services. Schedule 7A shows the applicant projects Medicaid at 5.6 percent of total patient days and other care at 11.0 percent for years one and two.

Odyssey Healthcare of Marion County, Inc. (CON #10019) states it has consistently provided care to all patients in need of its services, including the traditionally underserved Medicaid/charity/indigent population. The applicant states that 60 percent of Odyssey HealthCare Inc.’s FY 2007 non-Medicare net revenue is Medicaid and 1.2 percent of services are provided to indigent/charity patients. Schedule 7A shows $31,846 for charity care in year one and $99,011 for charity care in year two. Charity care will account for two percent of total patient days for both year one and two. Odyssey’s patient day Medicaid percentage is projected at three percent for years one and two. VITAS Healthcare Corporation of Florida (CON #10020) states that it provides in excess of one percent of revenues in charity care. For fiscal year 2007, this amount exceeded $9.8 million having increased from $8.5 million in 2006 according to the applicant. Schedule 7A shows $84,488 for charity care in year one, and $36,957 for charity care in year two. Charity care will account for 8.4 percent of total patient days in year one and one percent in year two. VITAS’s patient day Medicaid percentage is projected at 7.4 percent for year one and 8.0 percent for two.

HPH-Haven Alliance, Inc. (CON #10021) states that both its sponsors have a long standing history of providing a substantial amount of health care and services to Medicaid patients and the medically indigent going beyond the Medicare Conditions of Participation or Florida licensure requirements for hospice providers. Hernando-Pasco hospice states it provided 4.7 and 3.5 percent of patient days during 2006 and 2007 to Medicaid patients. Haven states it provided 6.9 percent and 8.6 percent of patient days during 2006 and 2007 to Medicaid patients, and 1.7 and 1.6 percent of patient days to indigent/charity care patients during the same period. According to Schedule 7A, self-pay will account for two


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percent of total patient days for year one and two respectively. Alliance’s patient day Medicaid percentage is projected at nine percent in year one and two respectively. Voyager HospiceCare, Inc. (CON #10022) states it has a history of providing hospice services to Medicaid patients and the medically indigent. In 2007, Voyager states its programs provided hospice services to 4,173 Medicare and 211 Medicaid patients representing 88.4 and 4.5 percent of total admissions respectively. Additionally, Voyager states it provided hospice services to 71 self-pay patients representing 1.5 percent of total admission in 2007. Schedule 7A shows $31,887 for charity care in year one, and $37,091 for charity care in year two. Self-pay/charity care will account for 3.95 percent of total patient days in year one and 1.5 percent in year two. Voyager’s patient day Medicaid percentage is projected at 4.49 percent in year one and 4.50 percent in year two.

G. RECOMMENDATION

Approve CON #10019 to establish a new hospice program in Hospice Service Area 3B, Marion County. The project involves a total project cost of $584,998 with year one operating costs of $1,574,550 and year two costs of $2,998,618. CONDITIONS: 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 to two percent of

patient days. This will be measured via a signed declaration 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 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.


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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.

6. The applicant commits to having every patient 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 (PI) 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 availability 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 provided 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 publication of the relevant collateral materials for the provider and patient community.

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

first year of operation. This will be measured via submission of the names and other relevant information of the ethics committee members and the related schedule of meetings to AHCA.

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 ethics committee members and the related schedule of meetings to AHCA.


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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 and staff of the existing provider. In-service training will 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 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 adults 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 formally 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 by the applicant’s inclusion of Dream Foundation information in Odyssey’s collateral materials.

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

Foundation, will make a $40,000 contribution to an appropriate not-for-profit entity in the community to fund education for end-of-life issues. If approved, 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.


the development efforts of a children’s hospice program in the Marion County community. The children’s program will offer an expanded hospice benefit for patients up to age 21. This program will 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. After one year and as the census of pediatric and PIC patients increases, dedicated staff


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will be increased to constitute a CSFP (Child and Family Support Program) interdisciplinary team. This will be measured via a signed declaratory statement by the applicant.


the development efforts for community bereavement programs in the Marion County 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 Marion County. 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 year one, full-time staff will be employed. This will be measured via a signed declaratory statement by the applicant.

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

Hispanic 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. Bereavement services will include Hispanic children. This will be measured via a signed declaratory statement by the 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 Foundation will establish

a Children’s Bereavement Camp in Florida by the end of the first year of operation, replicating what currently exists in Odyssey’s SkyCamp. This will be measured via a signed declaratory statement by the applicant.

20. The applicant will have a minimum of three Community Education

Representatives staff members, 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


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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. Finally, as evidenced by conditions defined above and by Odyssey’s

broad array of proven hospice services, programs and resources discussed in detail throughout this application, the applicant will model the proposed new hospice program as a Comprehensive Hospice Center as defined in The Florida Model of Hospice Care, A Report for Florida Hospices and Palliative Care, Inc., prepared February, 2004 by the Center of Gerontology & Health Care Research, Brown University School of Medicine. This study is presented in Appendix R. Examples of the research/academic endeavors and community advocacy activities beyond Community Hospice Model activities that support the applicant’s comprehensive hospice center condition include: • Providing Odyssey University on-line training and educational

resources to the community, • Participating with and promoting Dream Foundation activities

and fund raising, • Providing $40,000 to the local market to support enhanced

education for end-of-life care, • Providing dedicated staff for children’s hospice initiatives and

for community bereavement activities, • Establishing a Florida Children’s Bereavement Camp, and • Sponsoring and participating in national hospice care

educational activities including but not limited to support of and participation in the National Palliative and Hospice Care Organization, the Symptom Control and Palliative Care Fellowship Program at the University of Texas’s M.D. Anderson Cancer Center, the Palliative Care Fellowship program at the University of Alabama at Birmingham Fellowship through the Greater Birmingham Palliative Care Fellowship Program and the Clergy End-of-Life-Education Program at Baylor University.

This will be measured via a signed declaratory statement by the applicant. As previously stated, proposed conditions that require reports would be reported in the annual condition compliance report as required by Rule 59C-1.013 (4) Florida Administrative Code.


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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

Documents

ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT ...ahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10017.pdf · ON APPLICATION FOR CERTIFICATE OF NEED A. PROJECT IDENTIFICATION 1. Applicant/CON