state agency action reportflorida anesthesia consultants, p.a., bradenton, florida. one supporter...

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION 1. Applicant/CON Action Number

Evercare Hospice of Manatee County, Inc./CON #9960 601 Brooker Creek Boulevard Oldsmar, Florida 34677 Authorized Representative: Ms. Patricia Ford (888) 437-4673

HCR Manor Care Services of Florida, Inc./CON #9961 333 North Summit Street Toledo, Ohio 43604 Authorized Representative: Mr. Bruce Schroeder (419) 252-5668 LifePath Hospice & Palliative Care, Inc./CON #9962 12973 Telecom Parkway

Temple Terrace, Florida 33637 Authorized Representative: Ms. Kathy Fernandez

(813) 871-8111

Odyssey Healthcare of Manatee County, Inc./CON #9963 717 North Harwood Street, Suite 1500 Dallas, Texas 75201 Authorized Representative Mr. W. Bradley Bickham (214) 245-3176

CON Action Numbers: 9960-9964 & 9972

The Hospice of the Florida Suncoast, Inc./CON #9964 5771 Roosevelt Boulevard Clearwater, Florida 33760 Authorized Representative Ms. Mary J. Labyak Samaritan Care Hospice of Manatee, Inc./CON #9972 930 Ridgebrook Road Sparks, Maryland 21152 Authorized Representative Ms. Melissa Warlow (410) 773-1176

2. Service Area/Subdistrict

District 6, Hospice Service Area 6C, Manatee County B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in Hospice Service Area 6C. However, letters of support were submitted by the applicants, as discussed below. Letters of support for each applicant are detailed below. Evercare Hospice of Manatee County, Inc. (CON #9960) included 15 thank you letters and two letters of support with its application. The thank you letters and comments submitted in the application were from families who utilized Evercare’s services in other states. Paul Malley, President, Aging with Dignity, Tallahassee Florida and J. Donald Schumacher, PsyD, President and CEO, National Hospice Foundation both submitted letters of support. None of the letters were from Manatee County health care providers or residents and the applicant did not submit any commitments from local health providers to contract for inpatient beds.

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CON Action Number: 9960-9964 & 9972

HCR Manor Care Services of Florida, Inc. (CON #9961) included 50 letters of support with its application in addition to two letters received by the Agency supporting this project. One letter each was received from: Peter Routsis-Arroyo, LCSW, President/CEO of Catholic Charities, Venice, Florida; Senator Michael S. “Mike” Bennett, The Florida Senate; Karla Evans, Assistant Administrator, Heartland Home Health Care & Infusion in Bradenton, Florida; Donna Haynes, County Commissioner, District 5, Bradenton, Florida; Cynthia Hughes Harris, PhD, OTR, FAOTA, Professor and Dean of Allied Health Sciences at Florida Agricultural and Mechanical University, Tallahassee, Florida; Susan Terry, C.E.O. Community Aids Network, Sarasota, Florida; Joseph J. Creevy, M.D., Intercoastal Medical Group, Sarasota, Florida; Melissa N. Guthrie, Casa Mora Rehabilitation and Extended Care, LLC, Bradenton, Florida; Loren Carlson D.O., University Family Healthcare P.A., Sarasota, Florida; Maureen S. Kelly, President/CEO of West Central Florida Area Agency on Aging, Inc.; Marshall D. Bedder, M.D. of Coastal Pain Management & Rehabilitation. Dr. Cynthia Harris, Florida A&M University, extends her full support to HCR Manor Care. Dr. Harris would like to establish a relationship between the proposed hospice and Florida A&M University’s School of Allied Health Sciences in order to establish internship opportunities for students. West Central Florida Area Agency on Aging, Inc. believes that the citizens of Manatee will be well served by the proposed hospice provider and offers its full support. Included in these letters of support were letters of intent to contract for inpatient beds: Regional Washington, Administrator, Riverfront Nursing and Rehabilitation Center in Bradenton, Florida and Daniel J. Friedrich III, President and CEO, Blake Medical Center in Bradenton, Florida. All other letters of support were from doctors and providers in Manatee County and the surrounding area illustrating the applicant’s ability to obtain referrals from area health care providers. LifePath Hospice & Palliative Care, Inc. (CON #9962) submitted 16 letters of support with its application. One letter each was received from: James Jennings, Resident Director, the Windsor (an assisted living residence) Bradenton, Florida; James J. Hanusa, M.D., Bradenton, Florida; N. Canada M.D., Bradenton East Medical, P.A., Bradenton, Florida; Cathy Emmett, BSN, MSN, ARNP, Manatee County resident; Britton Wright, MSW, Patient and Family counselor; Linda K. Dyer, Executive Director, Westminster Manor Bradenton, Florida; Maureen S. Kelly, President and CEO, West Central Florida Area Agency on Aging,

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Inc., Tampa, Florida; Anthony T. Pizzo, M.D., F.A.C.C., F.A.C.P., Bradenton Cardiology Center; Horacio J. Argeles, M.D.; Elaine M. Slocumb, PhD, RN-BC, Assistant Professor University of South Florida; Sandra A. Macomber, area resident; Stephanie Ohme, area resident. Dr. Elaine Slocumb, University of South Florida, states LifePath hospice has served Hillsborough County for over 20 years; its Department of Research has partnered with the University of South Florida’s End of Life Center to ensure that evidence-based care is identified and practiced. None of the letters submitted were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. The letters of support were predominately from Manatee County residents, employees of LifePath, providers and assisted living facilities, illustrating the applicant’s ability to obtain referrals. Odyssey HealthCare of Manatee County, Inc. (CON #9963) submitted four letters of support with its application. One letter each was received from: Dr. Gail Van Diepan; Dr. Jerrold Ecklind; Diane Boodram, Administrator; Dr. Paul Todd. All supporters state Odyssey HealthCare’s presence in their communities (Flagler and Volusia Counties) has made other Hospice programs increase their level of care. The above letters of support are from physicians who refer their patients to Odyssey Healthcare, Hospice of Palm Coast which is in Service Area 4B. None of the letters submitted were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. No letters were submitted for Manatee county residents to illustrate the applicant’s ability to obtain referrals. The Hospice of the Florida Suncoast, Inc. (CON #9964) submitted 31 letters of support with its application. One letter each was received from: Sharon M. Kimball, RN, MS, MBA, Vice President of Patient Care Services/Chief Nursing Officer, St. Petersburg, Florida; Karol Kerr, M.D., Pediatric Hematology/Oncology Associates Sarasota, Florida (other locations); Lynda Walker, Hematology-Oncology Case Manager; Susan Senecal, RN, MSN, Pain Management Team Member, All Children’s Hospital; Elizabeth Weltman M.D., Hospitalist Program, all Children’s Hospital; Charlotte M. Curtis, R.N., B.S.N., C.P.M., Director, Partners in Care, Children’s Medical Services; Donna Sicilian, LCSW, Ed.S, Supervisor, School Social Work; Jane Parker, B.A.N., R.N., I.C.D., Coordinator, Perinatal Loss Doula Service; Jay Wolfson, Dr. P.H., J.D.,

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Director, Florida Health Information Center, Principal Investigator, Florida Family AIDS Network; Jeffery L. Paonessa, M.D., Gulfcoast Oncology Associates; Renee L. Teal, RN, Senior Clinical Coordinator; Belinda G. Alexander, Case Manager; Dr. Tim Passmore, Senior Pastor, Woodland, The Community Church Bradenton, Florida; Stan Stead, M.D., M.B.A., President, Stead Health Group, Inc., Encino California; Scott Thomas, area resident; Albert W. Keyser, Pastor, Redeemer Lutheran Church; Ann Sullivan, R.N.; Clayton Garrett Ball, M.D., West Florida Anesthesia Consultants, P.A., Bradenton, Florida. One supporter states the Hospice of the Florida Suncoast’s six-week bereavement group helped them cope with the death of a child. None of the letters were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. The majority of the letters submitted were from Manatee County residents, providers and past employees, illustrating the applicant’s ability to obtain referrals. Samaritan Care Hospice of Manatee, Inc. (CON #9972) submitted four letters of support in its application. One letter each was received from: Katie Holton, Director of Case Management, Lakewood Ranch Medical Center; David J. Parsons, M.D., P.A. Orlando, Florida; Stephen J. Quaning, M.D., M.B.A. Orlando, Florida; Ebbie Diaz, R.N., Palliative Care Team Manager, Florida Hospital East Orlando. Writers have either referred patients or had direct contact with Hospice of Orange-Osceola (owned by Samaritan Care Hospice) and commend the organization for its quick response time, compassion, as well as support that is given to the family as well as the physician. The Lakewood Ranch Medical Center support was in the form of an e-mail and the Director of Case Management states that Manatee County hospital does not have any preferred relationships that she believes there is need for “chemo/radiation treatment after being admitted to a hospice”, and believes competition is good. There was no suggestion that the applicant has asked for a commitment to contract for inpatient beds. None of the letters were from hospitals or nursing homes in Manatee County offering commitments to contract for inpatient services. Other than the e-mail from the Lakewood Ranch case manager, no letters of support were submitted from residents, doctors, or providers in Manatee County to illustrate the applicant’s ability to obtain referrals.

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C. PROJECT SUMMARY

Evercare Hospice of Manatee County, Inc. (CON #9960) (Evercare) proposes to establish a hospice program in Hospice Service Area 6C, Manatee County. Evercare is a newly formed corporation but is part of a much larger organization, United Health Group. According to the applicant, United Health Group, an affiliate, has 10 licensed hospice programs; eight of which are Medicare-certified in eight states excluding Florida. While United Health Group does not currently operate a hospice program in Florida, the applicant states that it does have experience and an established presence in Florida. United Health Group employs: physicians (providing access to broad range of medical and surgical specialties), independent laboratories, physical therapists, rehabilitation centers, medical supply firms, diagnostic centers, and home health agencies, are located throughout the county with offices in Bradenton, Ellenton, Holmes Beach, Long Boat Key, Palmetto, Parrish, Sarasota, and University Park. The applicant has agreed to condition award of the CON upon providing non-covered services, such as, but not limited to palliative radiation therapy and palliative chemotherapy (related to the terminal diagnosis) as well as other therapies (music, massage, aroma and other holistic therapies). The applicant will also provide at least 1.5 percent of care as indigent/charity care. 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 applicant is proposing total project costs to be approximately $649,450 in year 1 and year two costs of 2,435,413. The project does not involve any construction costs. HCR Manor Care Services of Florida, Inc. (CON #9961) (HCR Manor Care) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. HCR Manor Care Services of Florida, Inc. is a Florida for-profit corporation that is affiliated with Manor Care, Inc. a publicly traded company and a provider of nursing home, assisted living, home health and hospice services throughout the United States. Through its operating group Heartland Home Health and Hospice, Manor Care operates over 50 hospice and home health agencies in 23 states, including six home health care agencies in Florida. Also through the HCR Manor Care operating group, Manor Care operates over 300 nursing home and assisted living facilities in 30 states, including 48 in Florida. In addition to a home health care agency in Manatee County, HCR Manor

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Care has four skilled nursing facilities and two assisted living facilities in adjacent Sarasota County. The applicant is proposing project costs of approximately $297,956 and year two operating costs of $3,067,900. There are no building or construction costs with this project. The applicant has not agreed that any measurable condition be placed on the CON. Rather it has stated that it will serve anyone seeking services as required by state and federal regulations for hospice services and if the state places a condition on the CON, it will annually report on that condition. LifePath Hospice & Palliative Care, Inc. (CON #9962) (LifePath) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. The proposed hospice’s office will be in Bradenton, Florida. LifePath Hospice also has programs in Hillsborough County, Hospice Service Area 6A, and Polk, Hardee, and Highlands Counties which is Hospice Service Area 6B. LifePath Hospice is a not-for profit, 501 (c) (3) charitable organization. The proposed project costs are $383,773 in year 1 for project development costs and start-up costs with year two costs at approximately 5,277,500. The applicant has agreed to conduct education and outreach programs in Manatee County aimed at enhancing access to non-cancer patients and to cancer patients who require expensive palliative therapies and increasing the lengths of stay of hospice patients as a condition, if awarded the CON. The applicant did not offer any way to measure this commitment. Odyssey HealthCare of Manatee County, Inc. (CON #9963) (Odyssey) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. Odyssey currently provides hospice services in Hospice Service Area 4B and 11.

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The proposed project cost is $464,720. This amount includes equipment costs of $68,000, project development costs of $46,720, and start-up costs of $350,000. There are no building or construction costs with this project. The applicant also agrees to condition award of the CON upon providing non-covered services, such as, but not limited to: palliative radiation therapy and palliative chemotherapy (related to terminal diagnosis) as well as other therapies (music, massage, aroma, and other holistic treatments). The applicant will spend at least $25,000 during the first two years of operation to provide or fund public education programs dealing with end-of-life planning. It also agrees to report the Department of Elder Affairs detailed set of data to the Agency on an annual basis. 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. The Hospice of the Florida Suncoast, Inc. (CON #9964) (Suncoast) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. The Hospice of the Florida Suncoast, Inc. is a non-profit hospice. Hospice of the Florida Suncoast currently operates a hospice program in Pinellas County, Hospice Service Area 5B. The proposed project cost is $228,225 in year 1. This cost includes equipment costs, healthcare consulting, and start-up costs. There are no building or construction costs with this project. The applicant states that it is willing to condition award of the CON upon the following: • Commitment of $250,000 annually for the first two years of operation

of Manatee Hospice specifically designated as seed money for programs and services outside of Medicare hospice benefit.

• The commitment of 0.5 FTE the first year of operation for the development efforts of a children’s hospice program in the Manatee County communities.

• The commitment of 0.5 FTE in the first year of operation for the development efforts for community bereavement programs in the Manatee County communities.

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• The commitment of one FTE to be operationalized the first year for the provision of caregiver services to hospice patients. The provision of caregiver services will be provided up to an amount of $33,750 (an estimated cost of $2.23 per day for a five-year period).

• 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 special outreach to Hispanic children.

• The provision of three FTEs to allow for uninterrupted 24-hour care seven days a week to be dedicated to evening and weekend services whose sole responsibility and oversight is that of evening and weekend care.

• Provision of an AIDS program that will collaborate with existing AIDS Service Organizations in Manatee County in meeting the needs of hospice patients with HIV.

• The development in one year of a community resource library. This library will include various lay and professional education pieces related to chronic illness, death, dying and bereavement.

• Within the first two years will hire a full-time physician who will develop physician services including palliative care consults within area hospitals, nursing homes and the community.

• The implementation of a teen volunteer program within the first two years of operation.

• The expansion in year 1 of The Hospice of the Florida Suncoast’s current children’s and family retreat programs to the residents of Manatee County.

• Beginning in year 1, a minimum budget of $1,200 per interdisciplinary team for the provision of special wish funds for hospice patients and families.

• The development, in year 1, of a minimum of one community advisory committee to be composed of residents reflective of the community whose purpose is to provide input and feedback about he needs of the Manatee County community and whose recommendations will be used in the future program development.

• In year 1, the formation of a Manatee Council of Hospice Ambassadors to lead fundraising efforts on behalf of The Hospice of the Florida Suncoast in Manatee County.

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It is noted that recent changes to the Florida Statutes require hospice programs to meet their CON conditions or loose their license unless good cause is demonstrated.1 Samaritan Care Hospice of Manatee County, Inc. (CON #9972) (Samaritan) proposes to establish a hospice in Hospice Service Area 6C, Manatee County. Samaritan Care Hospice of Manatee County, Inc., a wholly owned entity of Samaritan Care Hospice, LLC, is a newly formed corporation. Samaritan Care Hospice was organized to consolidate all of the hospice care activities of Fundamental Long Term Care Holdings, LLC, which through its subsidiaries, is a diversified provider of post-acute and other long-term care, including skilled nursing homes, assisted living facilities (ALFs), and long-term hospitals in addition to hospice services. According to the applicant, Samaritan owns, or manages, through various operating entities, a total of nine licensed and fully certified hospices in five states. Four of these are relatively new. There are five more mature programs, including Hospice of Orange-Osceola, which has been providing hospice care in Hospice Service Area 7B for more than a decade. The proposed project cost is $415,087. Of this 320,000 is anticipated to be equipment, leasehold improvement, and pre-opening costs, and $95,087 is development costs. There is no construction cost associated with this project. The applicant states that it does not wish to accept any conditions placed upon the CON, should it be awarded.

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.

1 s. 408.606(7), Florida Statutes. 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.

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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(2) 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 the financial analyst, Ryan Fitch, who evaluated the financial data.

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed projects with the criteria found in Florida Statutes, Sections 408.035 and 408.037; applicable rules of the State of Florida, Chapter 59C-1 and 59C-2, Florida Administrative Code.

1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C-1.0355, Florida Administrative Code.

In Volume 32, Number 40 of the Florida Administrative Weekly, dated October 6, 2006, the Agency for Health Care Administration published a need for one additional hospital program in AHCA District 6, Hospice Service Area 6C. for the January 2008 Hospice Planning Horizon. Hospice Service Area 6C is currently served by Tidewell Hospice and Palliative Care, Inc. Each co-batched applicant is applying in response to published need for a hospice program in Hospice Service Area 6C.

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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 applicant clearly demonstrated that any population in the service area had unmet needs. Each applicant is responding to published need for an additional hospice program for the January, 2008 planning horizon.

Although none of the applicants receive preference for this criterion because they have not clearly demonstrated there are populations of unmet need, each applicant has discussed serving populations they believe to be underserved. Evercare Hospice of Manatee County, Inc. (CON #9960) will provide hospice services to all patients who meet the criteria for admission to hospice; including populations whose hospice needs are currently not being met. Evercare states that the hospice utilization rate in Hospice Service Area 6C has been consistently below the statewide average, particularly for patients with a non-cancer diagnosis. It is noted that when there is an average, there are usually providers both above and below the average. Utilization trends alone are not an indication that the needs of non-cancer patients are not being met. Similar to co-batched applicant HCR Manor Care, the applicant also identifies a patient population that it serves in its programs outside of Florida where it offers “treatment along with traditional hospice benefits” such as tube feedings and “therapy that is considered aggressive or experimental, etc.”2 It is noted that Hospice is defined in the Florida Statutes as: a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family. Palliative care is defined as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering.

HCR Manor Care Services of Florida, Inc. (CON #9961) states that it has identified several populations with unmet needs in

2 CON #9960, page 46.

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Hospice Service Area 6C based primarily upon declining penetration rates that have now reached below the state average and the shorter lengths of stay for hospice patients than the average length of stay in Florida. HCR Manor Care asserts under service to these patient populations with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and Acquired Immune Deficiency Syndrome (AIDS) is identified through the proportionately low numbers of hospice patients in Hospice Service Area 6C compared to the state rate of hospice patients to deaths, or the penetration rate by disease state. However, as noted earlier, this is not a clear indication of an unmet need. HCR Manor Care makes a commitment to serve these populations and all populations, including minorities, are educated about benefits of hospice care through community education seminars, distribution of multi-lingual educational materials, and direct counseling utilizing trained staff and volunteers. Interpreters are also made available when needed. Members of the hospice care team will also become involved and coordinate educational events with the local chapter of the Cancer Society, Heart Association, Alzheimer’s Association and others. HCR Manor Care asserts that through its established relationships and proposed marketing and public outreach efforts for hospice care, access will improve throughout the service area, reaching minorities and other patient populations in need. It is noted that the applicant has not agreed to condition award of the CON upon this commitment in some measurable way. Like co-batched applicant, Evercare, utilization trends alone are not an indication that the needs of cancer, CHF, COPD and AIDS patients are not being met. Additionally, there is no clear utilization trend pattern as shown in the applicant’s chart from page 1-10 of the application. As shown below, the existing Manatee hospice provider’s rate is above the state average in 2004 and below it in 2005, for example.

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Hospice Admissions and Penetration Rate as a Proportion of Deaths For the Most Recent Three Years in

Hospice Service Area 6C and Florida Deaths Annual Admissions Penetration Rate Increase in

Rate Year 6C Florida Period 6C Florida 6C Florida 6C Florida 1996 3,069 152,697 7/96-6/97 944 45,265 30.8% 29.6% 1997 3,137 153,830 7/97-6/98 1,062 48,455 33.9% 31.5% 3.1% 1.9% 1998 3,254 157,160 7/98-6/99 1,253 52,341 38.5% 33.3% 4.7% 1.8% 1999 3,284 162,122 7/99-6/00 1,262 58,543 38.4% 36.1% -0.1% 2.8% 2000 3,355 162,839 7/00-6/01 1,320 65,923 39.3% 40.5% 0.9% 4.4% 2001 3,322 167,181 7/01-6/02 1,356 70,707 40.8% 42.3% 1.5% 1.8% 2002 3,329 167,702 7/02-6/03 1,352 76,294 40.6% 45.5% -0.2% 3.2% 2003 3,367 167,980 7/03-6/04 1,677 84,021 49.8% 50.0% 9.2% 4.5% 2004 3,265 167,937 7/04-6/05 1,716 86,258 52.6% 51.4% 2.8% 1.3% 2005 3,335 170,023 7/05-6/06 1,683 91,896 50.5% 54.0% -2.1% 2.7%

Source: Florida Need Projections for Hospice Programs and Florida Vital Statistics Annual Reports. Another area in which the applicant suggests need exists and is not being met is an area where the applicant appears to have demonstrated that it distinguishes itself from all other applicants and the existing Manatee County hospice provider. The applicant states that: “A fundamental distinction between HCR Manor Care Services of Florida and all other applicants and the existing provider is that the person who is terminally ill DOES NOT HAVE TO RELINQUISH HOPE in order to be served. In other words, the patient is met where he or she is psychologically, medically, spiritually and physically and with the hospice team develops a plan of care.”3

“In an informal survey of existing applicants in this batching cycle operating hospices, including Tidewell Hospice, were asked if enrollment could occur if the person seeking enrollment, whose physician had given a terminal prognosis, would be enrolled EVEN IF HE OR SHE continue to explore curative means. The answer given was “NO”.4 Further: a patient “does not have to have made a decision not to try and recover”.5 Section 400.6005, Florida Statutes provides the legislative findings and intent regarding hospice regulation as:

3 Page 1.3 CON #9961 4 Ibid. 5 Page 1.4 CON #9961

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The Legislature finds that terminally ill individuals and their families, who are no longer pursuing curative medical treatment, should have the opportunity to select a support system that permits the patient to exercise maximum independence and dignity during the final days of life. The Legislature finds that hospice care provides a cost-effective and less intrusive form of medical care while meeting the social, psychological, and spiritual needs of terminally ill patients and their families. The intent of this part is to provide for the development, establishment, and enforcement of basic standards to ensure the safe and adequate care of persons receiving hospice services. (bold underline added for emphasis). The Florida Legislature has clearly intended hospice care to be received by patients not seeking curative treatment. Hospice is defined in the Florida Statutes as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family. Palliative care is defined as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering.6 LifePath Hospice & Palliative Care (CON #9962) states its commitment to serving all eligible hospice patients. LifePath intends to establish a new office in Bradenton and contractually arrange inpatient and respite care services in Manatee County available to support the residents of Hospice Service Area 6C. However, the applicant did not provide letters of commitment to contract with any Manatee County Hospitals or nursing homes for inpatient care or with other health care providers for respite or residential services. LifePath states that non-cancer patients in Service Area 6C are especially underserved but did not support that statement with evidence. The applicant states that it believes it will raise the length of stay for hospice care by admitting patients earlier. However, evidence was not provided to demonstrate that the existing provider failed to admit patients as early as possible. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it has identified populations with unmet needs in Hospice Service Area 6C to include patients who desire the end-of-life experience offered by hospice, but who are not able to receive hospice services because they do not know how or because their physician does not refer them to hospice care, and a need to increase community and physician education in the African-American community in Manatee County and minority hospice

156 Section 400.601, Florida Statutes


access. However, the applicant did not demonstrate that the needs to these populations are not currently being met. In addition, Odyssey also intends to conduct local educational campaigns that promote hospice care and seek to increase public awareness of hospice care. Among the applicant’s stated conditions should it be awarded the CON was spending at least $25,000 during the first two years of operation to provide or fund public education programs dealing with end-of-life planning. Although the applicant has committed to providing this education and made that commitment measurable, it has not demonstrated that there are populations with unmet hospice needs in Manatee County. The Hospice of the Florida Suncoast, Inc. (CON #9964) proposes to serve what it believes are the unmet needs of children, residents with HIV/AIDS, patients without caregivers in the home to include paid caregiver placement and residential services in group homes, assisted living and nursing homes, Hispanic patients, and bereavement programs that extend beyond hospice patients and their families. Suncoast has agreed to condition award of the CON upon a number of non-core services and programs and the commitments made by the applicant are measurable. Among these commitments is employing a nurse with pediatric grief experience. Services to be offered in Manatee would include working with the school system, developing groups with grieving children, providing PIC services in collaboration with Children’s Medical Services and providing counseling to children and families of children and young adults dying of cardiac disease, AIDS and other causes. The Hospice intends to replicate its HEART (Hospice Education and AIDS Resource Team) program in Manatee, providing expert care through their team, education in the community and mental health services. Suncoast is also currently providing case management services through Ryan White Title IV funding to residents and will have a case manager on site in the Manatee Hospice center. Suncoast states that it has a longstanding history of provision of care to homeless persons and people without caregivers. At the onset, The Hospice will employ one (1) full-time equivalent (FTE) caregiver to provide services to people without caregivers.

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Additional charitable donations will be sought to increase the service as needed. Bilingual staff will be hired to serve the Hispanic community with particular attention being paid to systematic outreach, education, support groups and recruitment of volunteers and staff in the Hispanic community. Bereavement support for the community will initially employ a social worker to develop and provide individual counseling and groups throughout the community for bereaved persons who are grieving the loss of a loved one not served in hospice. However, the applicant did not demonstrate that there was any population in Manatee County with unmet needs. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) stated that it has identified delays in response time in following up on referrals to hospice care as the unmet need for Hospice Service Area 6C. Samaritan reports that there have been delays of more than 24 hours and sometimes extend beyond 48 hours for patient admissions. Samaritan proposes to address this unmet need through a follow-up by phone or in person with every referred patient or family within two hours, and will meet with them face to face within 24 hours. This is the current standard among existing programs, and Samaritan will emphasize these standards in the proposed Manatee County program. Although the applicant has not agreed for conditions to be placed upon award of the CON, should the CON be awarded, this stated intent would be placed as a condition upon its CON under the authority of section 408.040(1)(a), Florida Statutes: The agency may issue a certificate of need, or an exemption, predicated upon statements of intent expressed by an applicant in the application for a certificate of need or an exemption. However, although the applicant states that it confirmed with area providers that admission to the existing program is delayed more than 24 hours, no evidence to support that statement was provided. Evidence that might have been provided includes letters from individuals or agencies contacted by the applicant stating that admission was delayed more than 24 hours.

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(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.

Evercare Hospice of Manatee County, Inc. (CON #9960) plans to provide inpatient care through existing agreements with licensed hospital and skilled nursing facility beds to serve patients in need of hospice services. However, the applicant did not provide letters or sample contracts form any local hospital or nursing home to demonstrate its ability to contract for inpatient beds. HCR Manor Care Services of Florida, Inc. (CON #9961) 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. It is noted that HCR Manor Care intends to establish an inpatient hospice facility when stabilized occupancy in the proposed hospice program (pending approval) is attained. It is understood that HCR Manor Care Services of Florida, Inc. would need to be awarded a second CON for a freestanding inpatient facility in order to establish this facility. Two letters of intent to enter into the provision of inpatient service were provided in the application: one from Riverfront Nursing and Rehabilitation Center, Bradenton, Florida and the other from Blake Medical Center, Bradenton, Florida. The applicant has demonstrated its ability to contract for inpatient beds. LifePath Hospice and Palliative Care (CON #9962) proposes to provide inpatient hospice care through contractual arrangements with existing nursing homes and hospitals. However, the applicant did not provide letters or sample contracts form any local hospital or nursing home to demonstrate its ability to contract for inpatient beds.

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Odyssey HealthCare of Manatee County (CON #9963) proposes to use existing licensed hospital and skilled nursing facility beds to serve patients in need of episodic and respite care services rather than developing new long-term/inpatient facilities exclusively for hospice services. Although the applicant states that it will contract with acute care providers and skilled nursing facilities in Manatee County no evidence was presented to support that statement. The Hospice of the Florida Suncoast, Inc. (CON #9964) commits to provide inpatient care to hospice patients at the onset through contractual arrangements with existing providers. Suncoast states that it has secured a verbal commitment of a likely unit from Lakewood Ranch Medical Center. It is Suncoast’s intent to initially contract for “scatter-beds” in hospitals and nursing homes with the 24-hour RN staffing available and to proceed with a contract for a hospice inpatient unit with Lakewood Ranch Medical Center. The applicant states that it foresees no difficulty in securing such contacts in Manatee County. However, like all co-batched applicants except HCR Manor Care, its ability to do this was not demonstrated. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) plans to provide approximately two to three percent of its total patient days to inpatients. According to the applicant, this proportion of inpatient care is consistent with Samaritan’s experience in its existing operations in Florida. In any event, Samaritan Care Hospice states that it will establish all necessary agreements with hospitals and nursing homes upon initiation of services in Manatee County, and expects to provide all of its Manatee inpatient hospice care through such agreements. However, like all co-batched applicants except HCR Manor Care, its ability to do this was not demonstrated.

(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. Evercare Hospice of Manatee County, Inc. (CON #9960) will provide services to all patients who meet the criteria for admission to hospice; including patients who do not have primary caregivers at home; the homeless; and patients with AIDS. Evercare Hospice’s admission policy states:

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Services are available to all terminally ill persons and their families without regard to age, gender, national origin, sexual orientation, disability, diagnosis, cost of therapy, ability to pay, or life circumstances. Evercare Hospice shall no impose any value or belief system on its patient or their families and shall respect the values and belief systems of its patients and families. The applicant did not describe how it plans to take care of the homeless and those without caregivers. HCR Manor Care Services of Florida, Inc. (CON #9961) states that it has a longstanding policy that expresses the company’s commitment to serving patients who do not have primary caregivers at home, the homeless, and patients with AIDS. The applicant asserts that when a 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. The applicant indicates that the lack of a home or a primary caregiver will not result in a person foregoing the hospice benefit. HCR Manor Care commits to provide hospice services to all, without discrimination: HCR Manor Care Hospice Services 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/seven days per week…. The applicant provided letters of support from a nursing home facility and hospital stating it could contract services with those local providers. LifePath Hospice and Palliative Care, Inc. (CON #9962) states that it serves all eligible patients and their families without regard to primary caregiver status, homelessness or HIV status and commits to extend these practices to support the residents of Hospice Service Area 6C. The applicant provided a description of its hospice caregiver program.7 The applicant did not provide evidence that they can contract with local providers for beds to ensure that it can provide care to the homeless. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it provides services to all patients who meet the criteria

7 Appendix S-18 description of the LifePath Hospice Caregiver Program CON #9962

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for admission to hospice. This includes patients who do not have a primary caregiver at home, the homeless, and patients with AIDS. Odyssey HealthCare’s 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. The applicant states that in a case where a patient is impaired with physical problems and can no longer be managed at home, or if a patient is homeless, Odyssey’s nurse evaluates the patient for possible inpatient admission to a hospital or long-term care facility. However, the applicant did not provide evidence that they could contract with local providers. The Hospice of the Florida Suncoast, Inc. (CON #9964) states its longstanding history of provision of care to homeless persons and people without caregivers in Pinellas County. At the outset, the applicant states that it will employ one (1) FTE caregiver to provide services to people without caregivers. Additional charitable donations will be sought to increase this service as needed. Suncoast will also be providing, through its interdisciplinary team, services to residential patients in assisted living and group home environments. As the program matures, the applicant plans to investigate the feasibility of building a hospice residence or contracting for space in an assisted living facility. The applicant did not provide evidence of its ability to contract with assisted living facilities or group homes in Manatee County. However, as noted earlier, the applicant has agreed to condition award of the CON upon providing caregiver services. Suncoast plans to extend its HEART (Hospice Education and AIDS Resource Team) program in Manatee, providing expert care through our team, education in the community and mental health services. Also through its affiliate, AIDS Service Association of Pinellas (ASAP), the Manatee service center will house an ASAP case manager currently providing case management services to Manatee residents. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) seeks to make services available to all who need them, regardless of circumstances. The applicant states its approach to hospice care is to actively seek to reduce and remove barriers to care whenever they may arise for a prospective patient, whether internal or external barriers. It is Samaritan’s goal to respond to every

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request for assistance by offering some level of support, including information, education, counseling, referral to community resources, and (if appropriate) direct care by palliative team. At the most basic level, Samaritan’s approach is that everyone who wants hospice care and meets service area requirements and physician certification is admitted. Throughout its operations the applicant states it strives to prevent denial or delays of admission to hospice caused by restrictive admission criteria, caregiver status, diagnosis, type and nature of palliative treatments, preferences for resuscitation, complexity of care, site of care, reimbursement source or cost of care. The applicant states that it has a continued commitment to serve the homeless, persons without caregivers, and persons with AIDS, as well as all others for whom hospice and palliative care is appropriate and beneficial. The applicant did not describe how it plans to take care of the homeless and those without caregivers. Evidence was not provided demonstrating the applicants’ ability to contract with local providers and unlike co-batched applicant Suncoast, has not agreed to condition to provide services to ensure this occurs beyond what is required by hospice regulation.

(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 6C consists of one county, Manatee. 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. With the exception of HCR Manor Care and Samaritan, each co-batched applicant has agreed to condition award of the CON upon providing uncovered services. It is noted that LifePath’s did not offer a way to measure its proposed condition.

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Evercare Hospice of Manatee County, Inc. (CON #9960) has conditioned this CON application such that it will provide non-covered services, such as, music, massage, aroma, therapies and other holistic treatments. Evercare states that it also provides other services that are not specifically covered, including but not limited to: (1) Bereavement services for more than one year, (2) “Face to Face” personalized bereavement services, not just letters and telephone calls, (3) Educational in-services to the medical community on end-of-life issues, (4) Attending all patient deaths, (5) Evercare nurse practitioners will insure seamless care and encourage the NP to remain involved in the care of the patient and family. HCR Manor Care Services of Florida, Inc. (CON #9961) indicates that it works with each patient, and if hope for a cure is held, will help provide the options, and will cover the cost of care that the individual seeks as part of the exploration of options. As noted earlier, the applicant’s commitment to offer services to patients who want to receive curative treatment suggests that it intends to operate outside of the statutory definition of a hospice program.8 In addition to the core hospice services including continuous care during periods of crisis and bereavement services, the applicant has established a program of Sincerus Care. Sincerus Care, according to the applicant, is a philosophy of both attitude and action that helps sustain the highest quality of life, even under challenging circumstances. The Sincerus Care concept helps to emphasize the positive aspects of body, mind and spirit – as individuals, and as a connected community. Outcomes of Sincerus Care Management according to the applicant include: (1) Comfort for the patient (2) Care delivered in home or in a facility, including assisted living and skilled nursing (3) Quality of life (4)

8 Florida Statutes Chapter 400.6005 Legislative findings and intent.--The Legislature finds that terminally ill individuals and their families, who are no longer pursuing curative medical treatment (emphasis added), should have the opportunity to select a support system that permits the patient to exercise maximum independence and dignity during the final days of life. The Legislature finds that hospice care provides a cost-effective and less intrusive form of medical care while meeting the social, psychological, and spiritual needs of terminally ill patients and their families. The intent of this part is to provide for the development, establishment, and enforcement of basic standards to ensure the safe and adequate care of persons receiving hospice services. Section 400.601(3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. Section 400.601(3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering.

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Culturally sensitive provision of services (e.g. Hispanic, African, Haitian, as well as others) (5) Management of symptoms of terminal disease (6) Bereavement services and counseling. As noted earlier, the applicant has not agreed that any measurable condition be placed on the CON. Rather it has stated that it will serve anyone seeking services as required by state and federal regulations for hospice services and if the state places a condition on the CON, it will annually report on that condition. If the CON is awarded the applicant will be conditioned to provide palliative therapies not covered by Medicare and other insurance, including Medicaid. LifePath Hospice and Palliative Care, Inc. (CON #9962) states that it provides the following services that are not reimbursable: (1) All hospice services for patients with a one-year or less prognosis, including interdisciplinary team support 24/7, medications, medical supplies and durable medical equipment as needed. (2) All hospice services for patients with a six-month or less prognosis who are uninsured or have exhausted insurance benefits, including interdisciplinary team support 24/7, medical supplies and durable medical equipment as needed. (3) Caregiver program which provides caregiver services to allow patients to stay in their home or assisted living facility. (4) Patient care supplies not deemed “medically necessary” such as diapers and underpads (chux) in the home and assisted living facility. (5) Non-health care items that provide quality of life and allow patients to stay in their home such as glasses, fans, and furniture. (6) The recruitment, training, support meetings and supervision of volunteers. (7) Message therapy, music therapy, pet therapy, hair stylists services, compassionate clown program, legacy program, comfort carts for patients in nursing homes, assisted living facilities and in the hospice house, dining assistance program. (8) Chaplain services to provide memorial services for patients, community memorial services or facility memorial services in nursing home, assisted living facilities or hospitals. It is noted that the applicant lists includes required core services and if needed by the patient are a part of the care covered by Medicare and Medicaid. The applicant has agreed conduct education and outreach programs in Manatee County aimed at enhancing access to non-cancer patients and to cancer patients who require expensive palliative therapies and increasing the lengths of stay of hospice

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patients as a condition, if awarded the CON. The applicant did not offer any way to measure this commitment.

Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it will be a “Community Hospice” as described by the Brown Study9. Briefly, the Brown Study describes a “Community Hospice” as a hospice that relies upon Medicare hospice revenues but in addition, provides services that reach a wider net of patients. This wider net probably includes patients that are not meeting Medicare hospice requirements, such as a six-month or less life expectancy. Under these conditions, a hospice may absorb patients earlier in the progression of a terminal or life-limiting illness and afford the patient a greater or higher quality of life. Generally, hospices that embrace successfully this “Community Hospice” model are hospices that are not solely dependent upon Medicare reimbursement to cover all of their costs and have other sources of revenue that will help off-set non-reimbursable charges. The applicant indicates it has intentions to operate in a “Community Hospice” environment and philosophy, but did not agree to condition award of the CON upon meeting the Brown Study’s depiction of a “Community Hospice”. As such it will provide services that are not specifically covered by private insurance, Medicaid or Medicare. These services include: 13 months of bereavement, pet, music, massage, and aroma therapies. At the corporate level Odyssey is also involved in education, research and advocacy on end-of-life issues in addition to providing non-covered services to insured patients. The applicant will spend at least $25,000 during the first two years of operation to provide or fund public education programs dealing with end-of-life planning. Hospice of the Florida Suncoast, Inc. (CON #9964) states that it provides services to all patients regardless of their ability to pay, including the provision of 11.5 million dollars of charitable care in Pinellas County in 2006. Suncoast states that it has developed a continuum of programs that fall outside any insurance coverage as part of its not-for-profit mission. These services would be replicated in Manatee County and would include: Public engagement activities such as community education, advance directive campaigns, a community resource library in the Manatee County Community Service Center, development of a community

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9 The Florida Model of Hospice Care – A Report for Florida Hospices and Palliative Care, Inc. 2004, Brown University School of Medicine


advisory committee; community programs including teen volunteers, caregiver support and education programs, HIV programs; palliative care programs, Faith-based outreach and development of partnerships, a quality of life fund for special wishes of patients and families, and bereavement services such as community bereavement groups and counseling for non-hospice bereaved, trauma and victims of crime services, community education on grief and loss, holiday grief programs and specialty support groups for the Hispanic population. Unlike other co-batched applicants, the applicant has offered a list of services it agrees to provide should the CON be awarded that include measurable conditions: • Commitment of $250,000 annually for the first two years of

operation of Manatee Hospice specifically designated as seed money for programs and services outside of Medicare hospice benefit.

• The commitment of 0.5 FTE the first year of operation for the development efforts of a children’s hospice program in the Manatee County communities.

• The commitment of 0.5 FTE in the first year of operation for the development efforts for community bereavement programs in the Manatee County communities.

• The commitment of one FTE to be operationalized the first year for the provision of caregiver services to hospice patients. The provision of caregiver services will be provided up to an amount of $33,750 (an estimated cost of $2.23 per day for a five-year period).

• 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 special outreach to Hispanic children.

• The provision of three FTEs to allow for uninterrupted 24-hour care seven days a week to be dedicated to evening and weekend services whose sole responsibility and oversight is that of evening and weekend care.

• Provision of an AIDS program that will collaborate with existing AIDS Service Organizations in Manatee County in meeting the needs of hospice patients with HIV.

• The development in one year of a community resource library. This library will include various lay and professional education pieces related to chronic illness, death, dying and bereavement.

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• Within the first two years will hire a full-time physician who will develop physician services including palliative care consults within area hospitals, nursing homes and the community.

• The implementation of a teen volunteer program within the first two years of operation.

• The expansion in year 1 of The Hospice of the Florida Suncoast’s current children’s and family retreat programs to the residents of Manatee County.

• Beginning in year 1, a minimum budget of $1,200 per interdisciplinary team for the provision of special wish funds for hospice patients and families.

• The development, in year 1, of a minimum of one community advisory committee to be composed of residents reflective of the community whose purpose is to provide input and feedback about the needs of the Manatee County community and whose recommendations will be used in the future program development.

• In year 1, the formation of a Manatee Council of Hospice Ambassadors to lead fundraising efforts on behalf of The Hospice of the Florida Suncoast in Manatee County.

If approved, these measurable conditions must be met annually or the applicant risks loosing its hospice license. Samaritan Care Hospice of Manatee County, Inc. (CON #9972) indicates that related company hospices currently provide a range of services that are not covered by private insurance, Medicaid, or Medicare, and will continue to do so in the program proposed herein for Manatee County. Specific non-covered services to be provided by Samaritan include: (1) Extubation or Ventilator Withdrawal Program – Samaritan Care states that it has developed expertise in assisting families and patients facing the difficult question of withdrawing mechanical breathing. (2) Supportive counseling or consultation with patients or families addressing issues of serious illness even if they do not qualify for a hospice benefit. (3) Service to citizens of other countries residing in the service area even if they have no hospice coverage. As noted earlier, the applicant states that it does not wish to accept any conditions placed upon the CON, should it be awarded. However, should the CON be awarded, any intent stated above that can be measured.

b. Chapter 59C-1.0355, Florida Administrative Code contains the following general provisions and review criteria to be considered in

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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.

Evercare Hospice of Manatee County, Inc. (CON #9960) states it will provide care and services under the advisory guidance of the Hospice Interdisciplinary Team (ITD). This team shall develop as well as review the Agency’s policies governing scope of services, admission and discharge policies, medical supervision and plans of care, emergency care, patient records, personnel qualifications and program evaluation. The applicant indicates that the ITD will also serve as a liaison with other health care providers in the community in order to identify any community needs. The interdisciplinary team will consist of at least the attending physician, hospice physician, registered nurse, social worker and spiritual counselor. The services of a volunteer, home health aide, and/or homemaker, registered dietitian, and properly qualified and certified occupational therapist, speech therapist and physical therapist may be included as appropriate to the care of the patient and family. This team, along with the participation of the patient and family, will develop the initial plan of care and participate in the periodic review and update which will occur at least every other week. The applicant states that volunteers are fundamental to the hospice concept and are a vital part of the hospice team, serving as inspiration to patients, families and staff. Evercare Hospice volunteers support patients and their families. Volunteers may work directly with patients and families, providing companionship and emotional support.

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Other volunteers contribute important organizational support, participating in program activities and helping with events and celebrations. Another specialized area of volunteering is bereavement, where volunteers help families navigate the grief process during the first year of loss. It is noted that there is no evidence of local support for this applicant or that the applicant can build its volunteer pool. HCR Manor Care Services of Florida, Inc. (CON #9961) 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. HCR Manor Care Hospice’s staff will consist of: clerical staff (includes office manager, team coordinator, receptionist, etc), director of professional services (DPS)/patient care coordinator (PPC), registered nurse and home health aide, RN, HHA staffing should be full-time employees, chaplain, medical social worker, volunteer coordinator, bereavement coordinator, admissions nurse to do a minimum of 10-12 admissions per week (the admissions nurse is included as part of the FTE RN). HCR Manor Care will seek volunteers for its new hospice program, and will employ a full-time volunteer coordinator for every 100 volunteers. Through the company’s existing network and initial public awareness campaigns, HCR Manor Care Hospice expects to recruit the volunteers needed for the new hospice. HCR Manor Care recognizes the important role that volunteers perform in the end-of-life care of patients. Volunteers offer support, companionship, and practical, caring help such as running errands, staying with the patient so family members can take a break, reading to patients, or be a caring friend. Volunteers with HCR Manor Care can also choose to participate in activities other than, or in addition to, direct involvement with patients and families, such as clerical help in the hospice office, conduct satisfaction and community surveys, and represent the hospice within the community. HCR Manor Care will provide volunteer orientation and ongoing training to ensure that volunteers have the skills needed to assist patients and their families. It is noted that the applicant provided letters of support from area health residents and care providers.

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LifePath Hospice and Palliative Care, Inc. (CON #9962): state that its proposed staffing is primarily based upon the existing LifePath Hospice staffing ratios. Staff will consist of counselors, RN’s, home health aides, nurse consultant, admissions RN, bereavement counselor, continuous care RN, LPN and HHA, pharmacist, pharmacy tech, chaplain, department secretary, resource coordinator, medical director, site-secretary, receptionist, and volunteer coordinator. The volunteer staff will number approximately about one per patient and will increase from about 40 in the first year to about 70 by the second year of operations. Volunteers will provide both administrative support and patient support functions.10

It is noted that the applicant provided letters of support from area residents and health care providers. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it will employ staff in administration, nursing, ancillary, dietary and social services. The administration for each Odyssey program consists of a general manager, patient care manager, community relations representative, admissions coordinator, office manager, and a patient care secretary. Each Odyssey hospice program employs home health aids and registered nurses; both full-time and on-call. The ancillary support function of Odyssey is handled by the bereavement coordinator, spiritual care coordinator and volunteer coordinator. Odyssey indicates that it uses an interdisciplinary team to meet and care for each patient. Upon approval, Odyssey-Manatee County will implement its interdisciplinary team of its employees. The manager of the interdisciplinary team is a nurse who assesses the needs of the patient and family and develops a specific plan of care with the physician. The nurse manager coordinates care with others on the team and the patient’s physician works with the hospice’s medical director to assure that the symptoms are controlled and pain is managed and keeps the patient and family informed. Other members of the interdisciplinary team are: a home health care aide, chaplain, social worker, trained volunteers, bereavement coordinator, and on-call nursing team.

10 See Appendix S-1 for information on the LifePath Hospice Volunteer Program. CON #9962

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At each program, the volunteer coordinator is responsible for recruitment and training of all volunteers according to the applicant. In the past volunteers have been recruited through civic organizations, church groups, colleges and schools, and many times friends and family of hospice patients according not the applicant. The applicant states that there are three segments of Odyssey’s Hospice volunteer program; a volunteer can either offer office support, indirect support or direct support. Direct support hospice volunteers provide companionship and support for patients by reading to them or writing letters for them. Indirect support volunteers may run small errands or give caregivers a brief respite by staying with the patient. As an office support volunteer, legal, accounting, or light office work is performed. Others may use talents to help patients with arts and crafts projects. The applicant indicates that all volunteers receive special training and will be under the direction of a staff member responsible for Odyssey-Manatee County’s volunteer program. As required by Medicare, Odyssey-Manatee County will document and maintain a volunteer staff sufficient to provide administrative or direct patient care in an amount that, at a minimum, equals five percent of the total patient care hours of all paid hospice employees and contract staff. However, as noted earlier the applicant provided no evidence of local support. The Hospice of the Florida Suncoast, Inc. (CON # 9964) states that hospice services will be delivered by trained members of an interdisciplinary team comprised of nurses, physicians, social workers, chaplains, home health aides and volunteers. This application is conditioned on three FTE’s to allow for uninterrupted 24-hour care seven days a week to be dedicated to evening and weekend services whose sole responsibility and oversight is that of evening and weekend care. All Suncoast volunteers will undergo a comprehensive training program designed to prepare them for their role in hospice according to the applicant. Training includes topics such as family dynamics, coping mechanisms and

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psychosocial issues associated with terminal illness, death and bereavement. The applicant states that all volunteers sign a confidentiality statement and all are supervised by a designated staff member. The applicant adds that although the majority of volunteers work directly with patients, many assist the organization in administrative and fundraising activities, contributing greatly to the organization’s mission and cost-effectiveness. The applicant provided evidence of local support. Samaritan Care Hospice of Manatee, Inc. (CON #9974) indicates that services will be provided or supervised by an interdisciplinary team (IDT). This team at a minimum will consist of: (1) a doctor of medicine or osteopathy, (2) a registered nurse: The Hospice designates an RN to coordinate the implementation of the plan of care for each patient, (3) a social worker, and (4) a pastoral/spiritual or other counselor. Samaritan anticipates that it will recruit, train and use volunteer staff at approximately the same proportion of overall staff as that currently found in its related company Orange-Osceola operation. In its most recent year Orange-Osceola recruited, trained and utilized the services of 24 individual volunteers who contribute nearly 1,000 hours of volunteer services to the organization and our patients. These services ranged from patient care activities to administrative and clerical activities, and assistance in fundraising activities according to the applicant. Samaritan anticipates a similar level of volunteer activity in Manatee County relative to their expected level of admission. However, as noted earlier, the applicant has provided no evidence of local support.

(b) Expected sources of patient referrals.

Evercare Hospice of Manatee County, Inc. (CON #9960) states it will actively seek out referrals throughout the community. It is anticipated that referrals will originate from: physicians, long-term care facilities, (e.g. nursing, homes, assisted living facilities and adult care centers), hospitals, managed care companies, and insurance

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companies. With Evercare’s established and active network of providers already in place in Manatee County, Evercare Hospice does not anticipate any difficulty in establishing relationships with local providers and receiving patient referrals. Although the applicant claims that it will not have difficulty establishing relationships within the community so that it will receive hospice referrals, it is noted that the applicant did not submit any letters of support from Manatee County health care providers. HCR Manor Care Services of Florida, Inc. (CON #9961) states that it expects to obtain referrals with organizations who are currently involved with its Heartland Home Health Care affiliate in Bradenton. According to the applicant, this affiliate is deeply rooted in the community and participates in many Manatee County community networks. The applicant received several letters of support for the project from local physicians and hospital staffs that expect to refer patients to HCR Manor Care Services of Florida, Inc. Patients and families may also refer themselves with the support and direction of an attending physician. HCR Manor Care also 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. Additionally, the applicant submitted letters of commitment from Regional Washington, Administrator, Riverfront Nursing and Rehabilitation Center in Bradenton, Florida and Daniel J. Friedrich III, President and CEO, Blake Medical Center in Bradenton, Florida. Lifepath Hospice and Palliative Care, Inc. (CON #9962) expects to obtain referrals from the same sources as it currently does in its existing service area. The applicant notes that in 2005, a majority of referrals have come either from physicians or hospitals. Hospitals are expected to represent 52 percent of referrals, physicians 26 percent, skilled nursing facilities 16 percent, and individuals/other six percent.

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As previously discussed, the applicant provided letters from local providers demonstrating its ability to obtain hospice referrals. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it expects to receive patient referrals from hospitals, physicians, patient self-referral, case managers, nursing homes/assisted living facilities, cancer care centers, home health agencies, continuing care retirement communities (CCRCs); elderly housing, families and neighbors of the terminally ill and those in crisis, places of religious worship, and community service groups. According to the applicant, in each of the markets served by Odyssey hospice programs, Odyssey 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. Odyssey works cooperatively with nursing homes and assisted living facilities to insure that their residents can receive hospice services without unnecessary hospitalizations or disruptive transfers to other facilities. However, as previously noted, Odyssey did not submit evidence that it has developed community relations and can obtain hospice referrals. The Hospice of the Florida Suncoast, Inc. (CON #9964) states its patient referrals will come from a wide variety of sources: physicians, nursing homes, assisted living facilities, hospitals, home health agencies, families and friends, managed care companies, and faith communities. As previously noted, the applicant has provided evidence of community support and demonstrated that it has relationships with community health care providers in order to receive hospice referrals. Samaritan Care Hospice of Manatee, Inc. (CON #9972) expects that its sources of patient referrals will be similar to that experienced in its Orange-Osceola operations. Those sources and proportions are as follows: skilled nursing

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facilities 30 percent, assisted living facilities 15 percent, hospitals 20 percent, physicians 20 percent, family and self-referral, and five percent from clinics. As noted earlier, the applicant has contacted a Manatee County hospital and there is some, albeit limited, evidence that it has community contacts to secure hospice referrals.

(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 1 (2008)

Year Two (2009)

9960 Evercare 195 340 9961 HCR Manor Care 189 257 9962 LifePath 251 294 9963 Odyssey 210 328 9964 Suncoast 245 406 9972 Samaritan 120 205

Source: CON Applications 9960-9964 and 9972. Evercare Hospice of Manatee County, Inc. (CON #9960) expects Medicare to comprise about 94 percent of the admissions during the first two years of operation and provided the following table for illustration.

Expected Admissions by Payer Type For Evercare Hospice of Manatee County Area 6C

Payer Type Year 1 Year Two Medicare 185 323 Medicaid 4 7 Self-Pay 4 7 Insurance 2 3 Other -- -- Total 195 340

Source: CON #9960 Application, page 66. As shown in the table above, the applicant intends to serve 195 and 340 patients in its first and second year of operation respectively. It is noted that the applicant’s expected provision of charity care is not referenced in this table.

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HCR Manor Care Services of Florida, Inc. (CON #9961) 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 HCR Manor Care Manatee County Area 6C

Payer Type Year 1 Year Two Medicare 136 186 Medicaid 42 57 3rd Party Insurance 6 8 Self-Pay 2 3 Charity/Other 4 5 Total 189 257 Source: CON #9961 Application, page 2-13 As shown in the table above, the applicant intends to serve 189 and 257 patients in its first and second year of operation respectively. HCR Manor Care has also included the projected percentage of charity/other care. LifePath Hospice & Palliative Care (CON #9962) 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 LifePath Hospice Manatee County Area 6C

Payer Type Year 1 Year Two Medicare 221 272 Medicaid 15 19 Other 3 3 Total 239 294 Source: CON #9962 Application, page 67. As shown in the table above, the applicant intends to serve 239 and 294 patients in its first and second year of operation respectively. It is not clear what payer type(s) is included in the “other” category. It is also noted that in all of the other information under this rule criteria, the applicant has indicated that it will provide a total of 251 admissions in year 1 and 309 admissions in year two. This discrepancy is not explained by the applicant.

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Odyssey HealthCare of Manatee County, Inc. (CON #9963) provided the following projected admissions by payer group.

Projected Number of Admissions By Payer Type For Odyssey Hospice Manatee County Area 6C

Payer Type Year 1 Year 2 Medicare 198 309 Medicaid 6 10 Self-Pay 4 6 Commercial Insurance 2 3 Total 210 328

Source: CON #9963 Application, page 62. *Applicant notes that this table is based upon the volume forecasts included in the financial forecasts present in the financial schedules of the application. As shown in the table above, the applicant intends to serve 210 and 328 patients in its first and second year of operation respectively. The applicant did not include the expectant projections for indigent patients or charity care. The Hospice of the Florida Suncoast, Inc. (CON #9964) 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 Hospice of the Florida Suncoast

Manatee County Area 6C Payer Type Year 1 Year 2 Medicare 208 346 Medicaid 15 24 Self-Pay/Indigent 12 20 Commercial 10 16 Total 245 406

Source CON #9964, Application pg. 77.

As shown in the table above, the applicant intends to serve 245 and 406 patients in its first and second year of operation respectively. Suncoast projects that five percent of its admissions will come from self-pay/indigent patients.

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Samaritan Care Hospice of Manatee, Inc. (CON# 9972) 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 Samaritan Care Manatee County Area 6C

Payer Type Year 1 Year 2 Medicare 94 159 Medicaid 12 22 Private Insurance 7 12 Indigent/Self-Pay 7 12 Total 120 205

Source: CON #9972 Application pg. 23 As shown in the table above, the applicant intends to serve 120 and 205 patients in its first and second year of operation respectively. Medicare in year 1 is expected to provide 78 percent of the admissions and in year two, 77 percent. Indigent and self-pay patients will make up approximately seven percent of admissions in year 1 and 12 percent of admissions in year two.

The Hospice of the Florida Suncoast, Inc. is projecting the highest total number of admissions at 406, consistent with the Agency’s projected January 2008 admissions of 416. Samaritan proposes the smallest program with a total of 205 estimated admissions. Each applicant projects that Medicare will be its highest payer type.

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

Evercare Hospice of Manatee County, Inc. (CON #9960) provided the following number of admissions by type of terminal illness:

Projected number of Admissions by Diagnosis For Evercare Hospice Manatee County Service Area 6C Disease Year 1 Year 2 Cancer 51 88 Alzheimer’s/Dementia 44 75 CHF 24 41 COPD 10 17 Debility 2 3 Renal 4 7 Liver/Other 60 109 Total 195 340

Source: CON # 9960 pg. 66 According to the information provided the applicant projects to serve 195 patients by year 1 and 340 by the end of year two of operation, 396 of which will be non-cancer patients (year 1 and two combined). The applicant is proposing to serve more non-cancer patients in a single year. HCR Manor Care Services of Florida, Inc. (CON #9961) 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 HCR Manor Care Manatee County Service Area 6C

Disease Year 1 Year 2 Cancer 74 100 Non-Cancer 115 157 Total 189 257

Source: CON #9961 pg 2-14 The applicant projects to serve 189 patients in year 1 and 257 patients in year two. The applicant included both cancer and other patients in its projections. LifePath Hospice and Palliative Care, Inc. (CON #9962) provided the following number of admissions by type of terminal illness. LifePath Hospice expects the large majority of its patients from Hospice Service Area 6C to have diagnoses other than cancer. In its illustration, LifePath

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included the projected number of admissions by two age groups, under 65 and 65 or older, for the first two years of operation.

Projected number of Admission by Diagnosis For LifePath Manatee County Service Area 6C


Source: CON #9962 pg 76 According to the information provided the applicant projects to serve 251 patients by the end of year 1, and 309 patients by the end of year two. As noted above, this chart and all of the following charts under this section for the applicant indicated a total of 251 admissions in year 1 and 309 admissions in year 2, rather than the 239 admissions in year 1 and 294 admissions in year 2 provided in response to the total number of expected admissions. The applicant does not explain this discrepancy. Odyssey HealthCare of Manatee County, Inc. (CON #9963) provided the following number of admissions by type of terminal illness. It is expected that the patients of the proposed hospice will be similar to that of Odyssey’s experience nationally.

Projected number of Admissions by Diagnosis For Odyssey Manatee County Service Area 6C

Disease Year 1 Year 2 Cancer 69 108 Renal 7 10 Alzheimer’s/Dementia 39 60 Heart 43 67 Liver 5 7 Lung 17 26 Debility 25 39 Other 7 11 Total 210 328

Source: CON #9963 pg 63 According to the information provided the applicant projects to serve 210 patients by the end of year 1 and 328 by the end of year two. Three hundred and sixty-one of those patients will be non-cancer patients.

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The Hospice of the Florida Suncoast, Inc. (CON #9964) 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 Hospice of the Florida Suncoast

Manatee County Service Area 6C Disease Year 1 Year 2 Cancer 107 178 Non-Cancer 138 228 Total 245 406

Source: CON # 9964 pg. 77

According to the information provided the applicant projects to serve 245 patients by the end of year 1, and 406 patients by end of year 2. Samaritan Care Hospice of Manatee, Inc. (CON #9972) provided the following table illustrating the projected number of admissions by terminal illness for the first two years of operation.

Projected Number of Admissions By Diagnosis For Samaritan Manatee County Service Area 6C


The applicant projects to serve 120 patients in year 1 with 61 percent of those patients being non-cancer patients; in year two the applicant projects to serve 205 patients with 60 percent of those patients being non-cancer patients. Each of the co-batched applicants expects to provide more services to non-cancer than cancer patients.

(e) Projected number of admissions, by two age groups, under 65 and 65 or older, for the first two years of operation. Evercare Hospice of Manatee County, Inc. (CON #9960) projects the following admissions by age cohorts.

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Projected Admissions by Age Group for

Evercare Manatee County Service Area 6C Under 65 Over 65 Total Year 1 29 166 195 Year 2 51 289 340 Total 80 455 Source: CON #9960 pg. 67 The applicant expects most of its patients in Hospice Service Area 6C to be over 65. In year 1 and two, 85 percent of patients will be over 65. HCR Manor Care Services of Florida, Inc. (CON #9961) projects 189 admissions in its first year of operations and 257 in the second year. The projected number of admissions by age groups under 65 and over 65 appears in the following table.

Projected Admissions by Age Group for HCR Manor Care Manatee County Service Area 6C

Under 65 Over 65 Total Year 1 28 161 189 Year 2 37 220 257 Total 65 381 Source: CON #9961 pg. 2-14 LifePath Hospice & Palliative Care, Inc. (CON #9962) projects 251 admissions in its first year of operations and 309 in the second year. The projected number of admissions by age groups under 65 and over 65 appears in the table below.

Projected Admissions by Age Group for LifePath Manatee County Service Area 6C

Under 65 Over 65 Total Year 1 38 213 251 Year 2 48 261 309 Total 86 474 Source: CON #9962 pg. 76 Odyssey HealthCare of Manatee County, Inc. (CON #9963) provides the following table for the projected number of admissions by age cohort. This table is based upon the volume forecasts included in the financial forecasts presented in the financial schedules of this application, 210 admissions in year 1 and 328 admissions in year 2.

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Projected Admissions by Age Group for

Odyssey Manatee County Service Area 6C Under 65 Over 65 Total Year 1 31 179 210 Year 2 48 280 328 Total 79 459 Source: CON # 9963 pg. 63 The Hospice of the Florida Suncoast, Inc. (CON #9964): In 2008, there are projected to be 42 admissions under age 65 and 204 admissions for patients age 65 and older. In 2009, these admissions will increase to 69 for patients under 65 and 337 for patients 65 and older.

Projected Admissions by Age Group for Hospice of the Florida Suncoast Manatee County Service Area 6C

Under 65 Over 65 Total Year 1 42 203 245 Year 2 69 337 406 Total 111 540 Source: CON #9964 pg. 77 Samaritan Care Hospice of Manatee, Inc. (CON #9972) 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 Admission by Age Group for Samaritan Manatee County Service Area 6C

Under 65 Over 65 Total Year 1 18 102 120 Year 2 30 175 205 Total 48 277 Source: CON # 9972 pg. 23 Consistent with each applicant expecting to provide more care to Medicare recipients than other payers, all applicants expect their respective patient populations to be over the age of 65.

(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

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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. Evercare Hospice of Manatee County, Inc. (CON #9960) states that with the exception of a minimal level of contact care provided by nutritionists, physical, speech or occupational therapists, the vast majority of hospice services will be provided by the hospice care team, including volunteers. Dietary is a core service and cannot be provided for through contract services. The applicant does not have an FTE for dietary services11. The applicant indicates that the manager of Evercare Hospice of Manatee County, Inc.’s interdisciplinary team will be the registered nurse case manager who assesses the needs of the patient and family and develops a specific plan of care with the physician. The registered nurse case manager coordinates care with others on the team and the patient’s physician, works with the medical director to assure that the symptoms are controlled and pain is managed and keeps the patient and family informed. Each interdisciplinary team will consist of at least the attending physician, hospice physician, registered nurse, social worker and spiritual counselor. The services of a volunteer, home health aide and/or homemaker, registered dietitian, a properly qualified and certified occupational therapist, speech therapist and physical therapist may be included as appropriate to the care of the patient family. This team, along with the participation of the patient and family, will develop the initial plan of care and participate in the periodic review and update which will occur at least every other week. HCR Manor Care Services of Florida, Inc. (CON #9961) asserts that with the exception of physicians, hospice core services will be provided by the hospice care 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: • RN’s and LPN’s (hospice staff)

11 See Schedule 6. CON #9960

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• 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) LifePath Hospice & Palliative Care Inc. (CON #9962) states that it will directly provide physician services, nursing services, home health aide services, social work services, chaplain services, counseling services and bereavement services. That applicant states that physical, speech and occupational therapy services and dietary counseling services will be provided through contractual arrangements. Dietary is a core service and cannot be contracted. The applicant does not provide an FTE on Schedule 6 for dietary services. Inpatient hospice services and respite services will be provided through contractual relationships as described in the next section (g). Trained volunteers will provide important services, and by performing administrative support functions. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that all services will be provided directly by hospice staff and volunteers with the following exceptions. Odyssey-Manatee County will contract with physicians, physical therapists, speech therapists, and occupational therapists for services. The need for nutritionists and therapist services is determined on an individual basis by the interdisciplinary team in consultation with the patient, family and attending physician according to the applicant. The applicant provides .03 FTE for dietary services. The Hospice of the Florida Suncoast, Inc. (CON #9964) states the following services will be provided directly by hospice staff and volunteers.

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• Skilled nursing services • Home health aide services • Medical social services • Physician services • Dietary counseling services • Spiritual counseling services • Bereavement services • Volunteer services • Patient and family education and support • Caregiver services • Clinical pharmacist • Physical, occupational and speech therapy • Palliative arts (e.g. massage, music therapy) Therapy services, including physical, occupational, and speech therapy as well as inpatient services, will be provided through contractual arrangements as needed. Samaritan Care Hospice of Manatee, Inc. (CON #9972) states that it will provide most of its core services directly by hospice staff and volunteers: • Nursing services • Social work services • Spiritual and counseling services • Dietary services • Bereavement counseling services • Home health aides • Homemaker and chore services The following additional services will be provided through contractual arrangements: • Physician services • Physical, occupational, & speech therapy • Patient transportation services • Infusion therapy

Other services that are needed on an occasional basis, such as daycare, handyman services, alternative therapies, or funeral services may be provided directly, if the requisite skills are available among our staff or volunteers, or they may be purchased on an as needed basis from reputable providers according to the applicant.

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It is noted that four of the six applicants have included allowable contracted services: HCR Manor Care, Suncoast, Odyssey, and Samaritan. The other two applicants, Evercare and LifePath have indicated that they plan to contract for dietary services and dietary counseling cannot be contracted.12

(g) Proposed arrangements for providing inpatient care.

Evercare Hospice of Manatee County, Inc. (CON #9960) will arrange for providing inpatient care through contractual arrangements with hospitals, nursing homes, assisted living facilities and other settings in District 6C. Evercare Hospice of Manatee County, Inc.’s parent company, UnitedHealth Group, currently has contracts with more than 300 hospitals within the State of Florida. Therefore, Evercare does not foresee any difficulty in securing contracts for outside services. However, as noted earlier, unlike four of the co-batched applicants: HCR Manor Care, LifePath, Suncoast and Samaritan, the applicant did not provide any evidence that could secure contracts because of demonstrated local support. HCR Manor Care Services of Florida, Inc. (CON #9961) will initially arrange for providing inpatient care through contractual arrangements with hospitals and nursing homes. Letters of intent to contract with HCR Manor Care Services of Florida, Inc. for the provision of inpatient beds are provided in Exhibit 2-1. Hospice inpatient care will be under the direct administration of the hospice, whether the inpatient facility is located in a nursing home or a hospital. The rooms within a facility used for the hospice patient component of care will be arranged, administered, and managed in such a manner as to provide privacy, dignity, comfort, warmth, and safety for the terminally ill patient and family.

4712 Section 400.0601, Florida Statutes


HCR Manor Care Services of Florida has stated intentions of establishing an inpatient hospice facility when stabilized occupancy in hospices is attained. It is noted that the applicant must apply for and be awarded the CON to establish a freestanding hospice facility. The applicant provided evidence of local support for the project. LifePath Hospice and Palliative Care, Inc. (CON #9962) states that it will provide inpatient hospice care in Hospice Service Area 6C through contractual arrangements with nursing homes and hospitals. The applicant provided evidence of local support for the project. Odyssey HealthCare of Manatee County, Inc. (CON #9963) will provide inpatient care through contracts with hospitals and nursing homes in District 6C. The applicant will make referrals to existing hospice inpatient units when appropriate. At this time Odyssey has no plans to construct a freestanding inpatient hospice facility. However, as noted earlier, unlike four of the co-batched applicants: HCR Manor Care, LifePath, Suncoast and Samaritan, the applicant did not provide any evidence that could secure contracts because of demonstrated local support. The Hospice of the Florida Suncoast, Inc. (CON #9964) will provide inpatient car through contractual arrangements with existing hospitals and skilled nursing homes in Manatee County. Suncoast will also seek a contract with Tidewell to admit patients to one of Tidewell’s inpatient facilities. Suncoast stated that it has received verbal commitment from Lakewood Ranch Medical Center to establish an inpatient hospice unit in their facility. However, unlike co-batched applicant Samaritan, the applicant did not provide evidence of support from that facility. Suncoast intends to also contract with Blake Memorial and Manatee Memorial Medical Center for inpatient services. The applicant provided evidence of local support for the project.

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Samaritan Care Hospice of Manatee, Inc. (CON #9972) expects to provide approximately two to three percent of its total patient days to inpatients. According to the applicant, Hospice of Orange-Osceola has contractual agreements with ten nursing homes for provision of inpatient care in Orange and Osceola Counties. Samaritan uses what it represents to be its contractual success in Orange-Osceola counties as an example of its anticipated success in Manatee County. The applicant proposes to establish all necessary agreements with hospitals and nursing homes upon initiation of services in Manatee County, and expect to provide all of their Manatee inpatient hospice care through such arrangements. The applicant provided evidence, albeit small, of local support for the project.

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

Evercare Hospice of Manatee County, Inc. (CON #9960) proposed no specific number of inpatient beds in this application. Evercare states that it will arrange for providing inpatient care through contractual agreements with hospitals, nursing homes, assisted living facilities and other settings in District 6C. It is noted that inpatient care may not be provided in assisted living facilities in Florida. As previously noted, evidence to support the applicant’s contracting for inpatient beds was not provided. HCR Manor Care Services of Florida, Inc. (CON #9961) did not provide a number if expected inpatient beds but rather indicates that it projects 189 hospice admissions the first year and 257 hospice admissions the second year and according to statute (Section 400.609(4), Florida Statutes), 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 for all the hospice patients of the licensed hospice. As previously discussed, the applicant expects to contract for inpatient care with local hospitals and

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nursing homes and when appropriate, seek CON approval to establish a freestanding inpatient facility. The applicant has provided evidence of its ability to contract for both skilled nursing and hospital acute care beds. LifePath Hospice & Palliative Care, Inc. (CON #9962) estimates that about six percent of its patient says will be inpatient hospice days for Service Area 6C during the first two years of operations. This is equivalent to a requirement for about three to four beds. Inpatient beds will be established through contractual arrangements in both nursing homes who meet the full Federal and State requirements to provide inpatient hospice services, and with hospitals. This would include the use of “scatter beds” in the facilities as well as dedicated hospice beds, as appropriate depending upon the particular needs of the community and the facilities. Overtime, LifePath expects that its requirements for inpatient beds will increase as its census grows and is the number of facilities it contracts with increases. Odyssey HealthCare of Manatee County, Inc. (CON #9963) is projecting 210 hospice admissions the first year of operation with an ALOS of 25 days and 328 hospice admissions the second year with and ALOS of 50 days. No specific number of inpatient beds is projected in this application. Odyssey-Manatee states that it will arrange for providing inpatient care and will arrange for providing inpatient care through contractual arrangements with hospitals, nursing homes and other settings. As previously noted evidence to support the applicant’s contracting for inpatient beds was not provided. Additionally, there are three venues of inpatient services and one is not through a contract, but rather the establishment of a freestanding inpatient hospice facility. The other two are skilled nursing beds and beds in an acute care hospital. There is no other setting for contracted inpatient beds. The Hospice of the Florida Suncoast, Inc. (CON #9964) proposes to contract for inpatient beds with existing providers. The applicant has stated that it has verbal commitments for contracts and did not provide documentation to support its ability to contract for beds. Samaritan Care Hospice of Manatee, Inc. (CON #9972) states that it will not seek to create dedicated units within

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nursing homes and hospitals. Rather the expected two to three percent of total patient days anticipated to be devoted to inpatient care will be provided through contractual agreement on an as needed basis. Documentation to support its ability to do that was not provided.

(i) Circumstances under which a patient would be admitted to an inpatient bed. Evercare Hospice of Manatee County, Inc. (CON #9960) explains that inpatient care is dictated by a patient’s medical need. If possible, symptoms are addressed and care is provided in the home setting – be that the patient’s home residence/nursing home or assisted living facility. Occasionally, this is not possible due to the need to manage acute symptomology that cannot be effectively managed in home setting, and when continuous care is not an option due to the level of caregiver support available, or patient or family wishes. At that point, patients are encouraged to seek the level of care with which they are most comfortable, including inpatient hospice care. To meet this need, Evercare would have to secure inpatient contracts with hospitals, nursing homes and any existing hospice inpatient unit in District 6C. As previously noted evidence to support the applicant’s contracting for inpatient beds was not provided. HCR Manor Care Services of Florida, Inc. (CON #9961): The applicant’s durable medical equipment contract 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. At that point, HCR Manor Care 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 choice, inpatient, residential or an alternative mode of care is provided. To meet this need, HCR Manor Care will establish contracts not only with it affiliates, but will also seek and

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secure inpatient contracts with hospitals and nursing homes outside the HCR Manor Care network within Hospice Service Area 6C to maximize available options. Evidence of the applicant’s ability to contract for these beds was provided. LifePath Hospice & Palliative Care Inc. (CON #9962) states that inpatient hospice care may be general inpatient care or inpatient respite care. Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual. Respite care may not be reimbursed for more than five consecutive days at a time. General inpatient care is available for pain control or acute or chronic symptoms that cannot be managed in other settings. Respite care and general inpatient care must be provided in a participating Medicare or Medicaid certified facility, which may include a hospice facility, a hospital, or skilled nursing facility. As previously noted, evidence to support the applicant’s contracting for inpatient beds was not provided. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that inpatient care is dictated by patient’s medical need. If possible, symptoms are addressed and care is provided in the home setting. Occasionally, this is not possible due to the need to manage acute symptomology that cannot be effectively managed in the home setting, and with continuous care is not an option due to the level of caregiver support available, or patient family wishes. Patients are encouraged to seek the level of care with which they are most comfortable. If the need happens to be inpatient care, Odyssey will secure inpatient contracts with hospitals, nursing homes and any existing hospice inpatient unit in District 6C. As previously noted, evidence to support the applicant’s contracting for inpatient beds was not provided. The Hospice of the Florida Suncoast, Inc. (CON #9964) explains that inpatient care is for short-term skilled care to manage symptoms that cannot be adequately managed at home. Patients at this level of care will be evaluated daily by the Suncoast interdisciplinary team to determine the continued need for inpatient care. Inpatient care is also appropriate in psychosocial situations in which caregiver is unwilling or unable to provide the skilled care at home. To meet the need for inpatient care, Suncoast will contract with hospitals and nursing homes in Hospice Service Area 6C. As

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previously noted, evidence to support the applicant’s contracting for inpatient beds was not provided. Samaritan Care Hospice of Manatee, Inc. (CON #9972) proposes that in addition to general admission criteria, admission by Samaritan to an inpatient bed will be based on one or more of the following acute care admission criteria: • Pain control • Symptom control • Imminent death with symptoms necessitating frequent

physician and nursing intervention • Medical-surgical procedures or therapies aimed at

palliation of symptoms • Family educational needs necessary in order to follow the

established plan of care at home • Provision of a safe supportive environment to the

terminally ill individual during periods of acute psychosocial and/or spiritual breakdown of primary caregiver(s)

• Primary caregiver incapable of continuing daily care in home setting

As previously noted, evidence to support the applicant’s contracting for inpatient beds was not provided.

(j) Provisions for serving persons without primary caregivers at home. Each of the co-batched applicants identifies provisions for serving persons without primary caregivers at home. Suncoast distinguishes itself by agreeing to condition award of the CON upon committing one FTE to be operationalized the first year for the provision of caregiver services to hospice patients. Suncoast also agrees, as a CON condition that the provision of caregiver services will be provided up to an amount of $33,750 (an estimated cost of $2.23 per day for a five-year period).

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Evercare Hospice of Manatee County, Inc. (CON #9960) states that it will provide hospice services to all patients who meet the criteria for admission to hospice; including patients who do not have primary caregivers at home, the homeless, and to patients with AIDS. Evercare Hospice’s admission policy states: Services are available to all terminally ill persons and their families without regard to age, gender, national origin, sexual orientation, disability, diagnosis, cost of therapy, ability to pay, or life circumstances. Evercare Hospice shall not impose any value or belief system on its patients or their families and shall respect the values and belief systems of its patients and families. Management of patient’s lacking a primary caregiver is often complicated by psychosocial and financial factors. In these cases, the RN team leader will schedule an interdisciplinary case conference soon after admission to address a definitive plan for ongoing patient care and primary caregiver support. A consultation will take place with the health services director and other designated staff regarding the situation and appropriateness of the patient for admission. HCR Manor Care Services of Florida, Inc. (CON #9961) 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 secured. LifePath Hospice & Palliative Care, Inc. (CON #9962) expresses that persons without primary caregivers at home receive hospice care from LifePath Hospice under special arrangements designed to maintain patient safety. Odyssey HealthCare of Manatee County, Inc. (CON #9963) indicates that it will provide services to all patients who meet the criteria for admission to hospice. This includes patients who do not have a primary caregiver at home, the homeless and patients with AIDS. Odyssey’s non-discrimination policy adopted by the applicant clearly states:

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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. If a patient is impaired and can no longer be managed in the home or homeless, the patient will be evaluated by an Odyssey nurse for possible inpatient admission to a freestanding hospice inpatient unit, hospital or long-term care facility. The registered nurse will coordinate the admission with the attending physician or hospice physician and the interdisciplinary team. The Hospice of the Florida Suncoast, Inc. (CON #9964) state that it has a special commitment to serving patients without caregivers in the home or with caregivers who can no longer accommodate the patient’s needs. Suncoast indicates that it developed a caregiver service in 1995 to allow patients to live and die in place, in their own residence. The caregiver program utilizes paid caregivers to help the patient for eight to 24 hours when there is an absence of a caregiver or a frail, elderly caregiver who is unable to provide necessary care when a patient becomes bed bound. Suncoast states that it provided $670,000 for caregiver services in 2006 and will fund caregiver services in Manatee County from the $250,000 seed money grant from The Hospice of the Florida Suncoast that is included as a condition to this application. The caregiver program is successful at keeping patients out of institutions, thus lowering the cost of care to the system. The caregiver program is a bridge between hospice home care and continuous care. Samaritan Care Hospice of Manatee, Inc. (CON #9972) states that the above circumstance is handled on a case by case basis, and every effort is made to address the specific needs of the patient and/or family. For those patients without a suitable primary caregiver at home, and appropriate caregiver network will be sought from among neighbors, nearby relatives and friends who are capable of providing the necessary amount of supervision and assistance to the patient within the patient’s or caregiver’s home. If there are too few qualified caregivers available to guarantee the safety of the patient, or if 24-hour care giving is required, qualified sitter services may be recommended to the patient/family in order to keep the patient in the home,

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where he/she can be most comfortable among familiar surroundings. Alternately, placement in an assisted living environment or nursing home may be appropriate in some cases, and would be arranged by Samaritan Care through relationships with assisted living facilities and nursing homes in the area. In this case, Samaritan Care would be able to provide residential care services as routine at home care to any hospice patient in a nursing home or assisted living setting.

(k) Arrangements for the provision of bereavement services. Evercare Hospice of Manatee County, Inc. (CON #9960) states that it provides bereavement counseling and services to the families of hospice patients for a minimum of 13 months following a patient’s death. The formal and informal supportive services which comprise bereavement services are supervised or provided by professional staff as required by local and state regulations. The bereavement program provides educational and spiritual materials and individual and group support services for the patient’s family after the death. Bereavement services are based on an assessment initiated at the time of admission and includes: patient/family grief and loss issues; the survivor(s) needs; social, religious, and cultural variables; risk factors; and potential for pathological grief reactions. A bereavement plan is developed which identifies services to be provided. Survivors with potential pathological grief reactions receive referrals for appropriate counseling services. There is ongoing regular, planned contact with the family, for at least 13 months, in a variety of ways that include individual face-to-face counseling, support groups, letters, and cards. Periodic assessments are conducted, as appropriate, to determine the bereavement needs of family members or significant others. Services will be provided through professional staff, and community resources according to the applicant. HCR Manor Care Services of Florida, Inc. (CON #9961) 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 coordinator (one per 80 census) in order to establish the types of bereavement

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programs that are provided throughout its national network of hospices. LifePath Hospice & Palliative Care, Inc. (CON #9962) states that it provides bereavement support to family members and loved ones for at least one year following death. LifePath Hospice also provides community bereavement services to persons who have been affected by the loss of a loved one who was not a hospice patient. Odyssey HealthCare of Manatee County, Inc. (CON #9963) indicates it will continue to care for the family even after the patient’s death. Each of Odyssey’s programs has a variety of options to help families through this most difficult time. Odyssey’s bereavement services, provided by qualified staff and volunteers, begin with the initial assessment upon admission of the patient. During the initial assessment, an RN assesses the possible needs of the patient and/or family members who may have grief/anticipatory issues. This assessment will begin the interdisciplinary approach to the bereavement plan of care. Odyssey’s program will have a designated bereavement coordinator from the psychosocial team who is responsible for the management of the bereavement program. Odyssey offers condolence correspondence, written materials, articles and resources, one on one counseling, bereavement letters, grief support groups, memorial services, and holiday bereavement program. The Hospice of the Florida Suncoast, Inc. (CON #9964) states that it extends its reach into the community by offering a wide range of programs for those affected by illness or loss of someone they care about. These programs are largely non-reimbursable, value-added services that promote emotional healing and help people with major life transitions. As part of the rich continuum of care provided by this organization, these programs not only enhance the life of the community, but also provide points of access to other hospice services. Many persons served by these programs have no relationship to a hospice patient, but have been affected by caregiver or loss issues.

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Suncoast intends to work with the Manatee community to identify needs and offer a range of programs based on community input. These services will be modeled after the bereavement programs Suncoast currently offers in Pinellas County which includes, individual counseling, trauma counseling, Kindred Hearts, support for professionals, holiday dinners, and children’s bereavement services. Samaritan Care Hospice of Manatee, Inc. (CON #9972) indicates that it currently has policies and procedures in place for provision of bereavement services, and expects to conduct similar bereavement services under the auspices of the Manatee County program. The patient, caregiver(s) and family are assessed for coping skills and bereavement risk factors. Community patients may be self-referred or referred by appropriate individuals or professionals. All families or affected parties will receive follow-up cards and telephone messages of caring. The initial Samaritan Care Manatee County office, to be located in the Bradenton, will encompass space for counseling and bereavement activities, and space will be arranged in other locations (e.g. churches, libraries) to meet the access needs of the community or specific space requirements of various programs as they develop.

(l) Proposed community education activities concerning hospice programs. Evercare Hospice of Manatee County, Inc. (CON #9960) states that its parent company operates the UnitedHealth Hospice Foundation. UnitedHealth Hospice Foundation’s objective, according to the applicant, is to provide education about the value of hospice care and work with leading, national hospice organizations to advance overall understanding of the hospice movement. The goal is to promote hospice care through community outreach activities, including collaborations with medical providers, social service and religious groups, hospitals and clinics, residential care facilities, and with patients and families themselves. As a member of UnitedHealth Hospice Foundation, Evercare Hospice Foundation’s objective is to provide education about the value of hospice care and work with leading, national hospice organizations to advance overall understanding of the hospice movement. The goal is to promote hospice care through community outreach activities, including collaborations with medical providers, social service and religious groups, hospitals and clinics,

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residential care facilities, and with patients and families themselves. HCR Manor Care Services of Florida, Inc. (CON #9961) 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 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. LifePath Hospice & Palliative Care, Inc. (CON #9962) indicates it will engage in extensive community education in partnership with existing health providers, service agencies, and houses of worship in Hospice Service Area 6C. An important element of community education program in Hospice Service Area 6C, according to the applicant, will be related to terminally ill patients with non-cancer diagnoses. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states that it implements a community education plan designed to address the specific needs of the patient referral sources in the market area and to promote the quality, responsive and comprehensive service that Odyssey-Manatee County will provide to patients and their families. Three or more dedicated community education representative will develop relationships with patient referral sources by regularly calling on these referral sources and educating groups of physicians, social workers, nurses, hospital discharge planners, assisted living facility personnel and nursing home personnel regarding hospice care in general and Odyssey-Manatee County services in specific. In addition, Odyssey-Manatee will conduct local educational campaigns that promote hospice care and seek to increase public awareness of hospice care. Odyssey plans to make

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special educational efforts with the African-American community in District 6C. The Hospice of the Florida Suncoast, Inc. (CON #9964) indicates that it provides community, consumer and professional education services as an integral part of its mission to serve everyone in the community affected by life-limiting illness, caregiving and bereavement. The applicant states that it accomplishes the educational component of its mission principally through The Hospice Institute of the Florida Suncoast. Educational programs are provided to our community as a way of supporting all people anticipating and experiencing illness, caregiving, or bereavement and those professionals serving these people to assure consumer choice in palliative care and competency of end-of-life care professionals. These programs are coordinated through the Hospice Institute of the Florida Suncoast and involve all 1,200 staff and 3,000 volunteers of the Hospice of the Florida Suncoast. In addition to staff and volunteers, the Institute also collaborates with paid consultants and outside educators to bring its education, training programs and consultative services to the community. Samaritan Care Hospice of Manatee, Inc. (CON #9972) states that its associated program in Orange and Osceola Counties currently has an active and effective community outreach and education program in its service area. Samaritan anticipates extending that program quickly and efficiently into the proposed service area. The core of this program is direct communications and presentations by our staff members to groups who are positioned to benefit from detailed information regarding the philosophy, benefits, and procedures of hospice care delivery. For the proposed Manatee County program Samaritan Care will initially have two community relations representatives dedicated to activities in the new service area, beginning upon initiation of services, with two additional positions expected to be added in year 2. They will be contacting the same types of organizations listed above to share the news of our availability in the service area, and to offer their services, share information, and develop opportunities for public educational and awareness.

(m) Fundraising activities.

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Evercare Hospice of Manatee County, Inc. (CON #9960) states that its parent company UnitedHealth Group has established a United Giving Campaign whereby employees are able to make payroll contributions to various 501 (c) 3 organizations of their own choosing. UnitedHealth Group also makes matching contributions to certain identified charities each year. According to the applicant, in 2006, Evercare Hospice & Palliative Care donated $25,000 to the National Hospice Foundation and was a Rockefeller Sponsor at the 2006 Gala even in New York City with the National Hospice and Palliative Care Organization. HCR Manor Care Service of Florida, Inc. (CON #9961) 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 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 $770,000 in 2005. The applicant also states that since the foundation was established, approximately two million dollars in grants have been made to diverse research, public education and community-based service programs in various stages of development throughout the country. LifePath Hospice & Palliative Care Inc. (CON #9962) indicates that fundraising helps pay for non-reimbursable programs and services and also raises community awareness about hospice care. The applicant indicates that income from fundraising is included in financial projections in line with the historical experience at LifePath Hospice. Funds donated by residents of Hospice Service Area 6C will be employed to enhance the effectiveness and availability of hospice care in Hospice Service Area 6C.

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Odyssey HealthCare of Manatee County, Inc. (CON #9963) indicates that it does not rely on fundraising as a source of funds for the operations of individual programs. According to the applicant, in 2005, the contributions program gave approximately $4.6 million in charity back to the communities it serves and an additional $568,777 through the Odyssey Foundation to causes specifically related to end-of-life issues and hospice. Odyssey’s annual contributions at the community level include: • Providing charity hospice care for needy patients. • Providing assistance to patients and families when their

financial circumstances prevent them from covering basic needs such as utility bills, travel for relatives to visit the terminally ill patient, burial expenses, air conditioning units, etc.

• Providing financial contributions to non-profit agencies. Odyssey-Manatee County will provide many services and “extras” that are not reimbursable. In many cases, that means that staff simply stays with the patient and/or family to provide the support that they need, provide bed sheets, funeral expenses or the blackberries. Other times, a great deal of time, effort and expense is required to meet the needs of patients and Odyssey-Manatee County will make every effort to meet those needs, regardless of reimbursement. The Hospice of the Florida Suncoast, Inc. (CON #9964) states that fundraising activities in Manatee County will be coordinated by the Hospice of the Florida Suncoast’s existing foundation. The Hospice Foundation of the Florida Suncoast was established in 1983 to raise and manage charitable contributions in support of the mission and services of The Hospice of the Florida Suncoast and its family of programs. Donations make possible a comprehensive range of interdisciplinary and volunteer services for those living with an advanced, chronic or terminal illness or condition, their families and caregivers, and those who have experienced the loss of a loved one. According to the applicant, in 2006, The Foundation received nearly $9 million in public support and contributions. The applicant states that a portion of these funds was reinvested in the local community through palliative care and residential hospice services, caregiver education and support, community education, nursing scholarships for workforce development, grief support services, child and family support programs and HIV/AIDS

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prevention education and services. Suncoast’s programs, according to the applicant, have earned major multi-year grants from national founders bringing new monies into the local community from outside sources. This capacity for securing grant funds from major foundations will be part of the fundraising strategy for Manatee. Samaritan Care Hospice of Manatee, Inc. (CON #9972) indicates that it has affiliates that undertake a variety of fundraising activities through their related foundations in each service area. These include contributions, bequests, endowments, memorials, and restricted donations from families, friends, and others who have been positively impacted by our services or believe in and support or activities. Samaritan supports an array of community benefit events in various service areas such as golf tournaments, walk-a-thons, and auctions. Samaritan anticipates that charitable contributions will initially constitute a relatively small proportion of our overall income in the Manatee County operations as it establishes a presence and increasing recognition in the community.

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 6C. Below is a table illustrating the square mileage for Manatee County in Hospice Service Area 6C along with population and population density.

Population density within Hospice Service Area 6C County

January 2007 Population

Square Miles

January 2007 Population Density

Manatee 319,120 692 430.55 Total 6C 319,120 692 430.55 State of Florida 18,624,120 53,937 345.29

Source: Florida Hospital Bed Need Projections by District, Volume I, published 1/26/07.

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The following chart illustrates the increase in hospice admissions for the past five years. As shown below, admissions have increased from1,320 in year ending June 30, 2001 in 2001 to 1,683 in year ending June 30, 2006.

Hospice Admissions for Service Area 6C Fiscal Years 2001 - 2006

Fiscal Year Admissions 07/05 – 06/06 07/04 – 06/05 07/03 – 06/04 07/02 – 06/03 07/01 – 06/02 07/00 – 06/01

1,683 1,716 1,677 1,352 1,356 1,320

Source: AHCA Florida Need Projections for Hospice Programs, 2001-2006 Evercare Hospice of Manatee County, Inc. (CON #9960) states that District 6C utilization levels (percentage of patients dying that access hospice care) have been below state averages very consistently throughout the last five years. Although the numbers are below state average this in itself is not evidence that there is unmet need. Evercare Hospice of Manatee County, Inc. will be held to the same high standards of quality that all Evercare Hospice and Palliative Care programs are held to nationwide. Evercare lists its medical model, open access enrollment, referral responsiveness, attendance at patient deaths, extended bereavement support, disaster preparedness, hospice certification, staffing ratios, electronic medical records, community support, provision of therapy that is considered aggressive or experimental13, and national leadership in provisions of services and products to seniors and those with disabilities as factors that give it a competitive edge over the existing provider and its co-batched applicants. However, the applicant has not provided documentation to support these claims.

13 Florida Statutes Chapter 400.6005 Legislative findings and intent.--The Legislature finds that terminally ill individuals and their families, who are no longer pursuing curative medical treatment (emphasis added), should have the opportunity to select a support system that permits the patient to exercise maximum independence and dignity during the final days of life. The Legislature finds that hospice care provides a cost-effective and less intrusive form of medical care while meeting the social, psychological, and spiritual needs of terminally ill patients and their families. The intent of this part is to provide for the development, establishment, and enforcement of basic standards to ensure the safe and adequate care of persons receiving hospice services. Section 400.601(3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. Section 400.601(3), Florida Statutes defines "hospice" as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family and (4) defines "palliative care" as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering

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As discussed earlier, unlike many of its co-batched applicants, Evercare has not provided evidence that it can obtain local support needed to provide the hospice services it proposes in this planning area. Additionally, Agency projections show the projected admissions minus the current admissions at 416. The applicant has proposed 340 admissions by year 2. Suncoast, on the other hand, estimates that it will admit 406 patients by year two suggesting that Evercare is proposing a smaller program by comparison. HCR Manor Care Services of Florida, Inc. (CON #9961) states that in Hospice Service Area 6C there is no alternative choice in hospice care; therefore, limiting the current hospices referral sources and public education initiatives. HCR Manor Care further expresses that this limitation can only be remedied through the addition of a second hospice provider to fill the gap and increase awareness to the medical community and the general public. However, as discussed earlier, the applicant has not shown that access is limited or that hospice services are not being provided. HCR Manor Care feels it has the experience and an established network of health care providers in the area to facilitate the establishment of a viable hospice program that would be well received by the public. The applicant has shown evidence of local support and ability to offer the services it proposes. As noted earlier, the applicant believes it has distinguished itself from other applicants by intending to target patients who want to receive curative treatment, indicating that patients it admits to its hospice program do not have to be ready to stop seeking a cure for the illness a physician has determined is terminal. It states that it conducted a survey to demonstrate that none of the co-batched applicants or the existing providers would enroll patients “if the person seeking enrollment, whose physician had given a terminal prognosis, would be enrolled EVEN IF HE OR SHE continue to explore curative means”. The applicant states that all co-batched applicants, presumably including Evercare, said “no” and that the existing hospice provider also said “no”. It is noted that Hospice is defined in the Florida Statutes as a centrally administered corporation providing a continuum of palliative and supportive care for the terminally ill patient and his or her family.

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Palliative care is defined as services or interventions which are not curative but are provided for the reduction or abatement of pain and human suffering. The applicant believes that with the presence of an HCR Manor Care affiliate and the backing of HCR Manor Care Services of Florida, Inc. it is positioned to meet the demand of published need and improve availability of hospice care in Manatee County. However, as noted earlier, the applicant proposed to reach admissions of 257 by year two. Agency projections show the projected admissions minus the current admissions at 416. Suncoast, on the other hand, estimates that it will admit 406 patients by year two suggesting that HCR Manor Care is proposing a small program by comparison. LifePath Hospice & Palliative Care Inc. (CON #9962) is an existing provider which proposes to extend its services into an adjacent service area - Hospice Service Area 6C. Although the applicant claims that there is unmet need because of what it describes as declining performance and short lengths of stay, which was not demonstrated, it is noted that, the applicant is not proposing a large program. The applicant proposed to reach admissions of 294 by year two by one of its counts and 309 in year two by another. Agency projections show the projected admissions minus the current admissions at 416. Suncoast, on the other hand, estimates that it will admit 406 patients by year two suggesting that LifePath is proposing a small program by comparison. Odyssey HealthCare of Manatee County, Inc. (CON #9963) states the need for an additional hospice program in District 6C is supported by the numeric need formula, as applied to the utilization of existing hospice programs in the service area. According to the applicant, the data also show that there is sufficient demand for hospice services without an increase in the penetration rate to support at least two hospices providing comprehensive services beyond those required by Medicare. However, this was not demonstrated by the applicant, as previously discussed. As noted throughout this report, the applicant has not provided evidence that it can provide care to the homeless or contract for inpatient beds in local hospitals and nursing home. Its ability to obtain referrals in Manatee County could have been supported by letters from local health care providers. However, as noted previously, the applicant submitted four letters of support. None were from the local area. The applicant proposed to reach admissions of 328 by year two. Agency projections show the projected admissions minus the current admissions

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at 416. Suncoast, on the other hand, estimates that it will admit 406 patients by year two suggesting that Odyssey is proposing a smaller program by comparison. The Hospice of the Florida Suncoast, Inc. (CON #9964) proposes to enhance availability of hospice services within Hospice Service Area 6C. Suncoast states that 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. Suncoast plans to use its Pinellas County hospice program as a template for services in Manatee County on the basis of the counties sharing some of the same demographic characteristics. Suncoast has staff working in Pinellas who reside in Manatee who are interested in being part of the initial team that will develop Suncoast hospice program. Suncoast believes that certain services can be shared between Pinellas and Manatee operations. The applicant states that the number of hospice admissions in Manatee County has grown over the last five years by approximately 38 percent to 1,767 admissions in 2005, and the fixed need calculation indicates that there will be 416 additional patients in the service area in 2008. Suncoast’s projected utilization in its second year of operation is less than the need identified, indicating, according to the applicant, that the existing provider will not be adversely affected by the approval of the Suncoast project. As noted earlier, Suncoast proposes the largest program, near the projected need. Suncoast has also distinguished itself by agreeing to measurable conditions if awarded the CON, to ensure that its proposed program offers improved access to hospice care, improved education regarding available hospice services, and to address any cultural barriers to hospice care in Manatee County. Samaritan Care Hospice of Manatee, Inc. (CON #9972) believes that availability, accessibility, quality of care, and extent of utilization in the service area will all be enhanced as the result of its approval and implementation of this program. The applicant notes that Hospice penetration rates have been increasing steadily in recent years

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nationwide, and throughout Florida. The applicant believes that the increasing use of hospice services reflects greater knowledge and acceptance of the hospice philosophy of end-of-life care among physicians, other health care providers, and the general populace. Of the co-batched applicants, Samaritan proposed to lowest number of admissions by year 32at 205. Agency projections show the projected admissions minus the current admissions at 416. Suncoast, on the other hand, estimates that it will admit 406 patients by year two suggesting that Samaritan is proposing a small program by comparison.

b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? Is the applicant a Gold Seal Program nursing facility that is proposing to add beds to an existing nursing home? ss. 408.035(3), 408.035(10), Florida Statutes.

Evercare Hospice of Manatee County, Inc. (CON #9960) is a newly formed corporation, but is part of a much larger organization, with experience in the delivery of hospice care and other health care services. Specifically the applicant is part of UnitedHealth Group (UGH), a diversified health and well-being company. According to the applicant, Evercare operates Evercare Hospice & Palliative Care which has 10 hospice programs (two new sites and eight Medicare-certified hospices) in eight states; Arizona (Phoenix and Tucson), Colorado (Colorado Springs and Denver), Georgia (Atlanta), Maryland (Columbia), Massachusetts (Boston), Ohio (Cincinnati – new), Texas (Houston-new), and Virginia (Vienna). The applicant did not provide copies of its hospice survey administered in states where its other programs exist to support its claims. The applicant states that Evercare is an active participant in both the Florida Frail Elder (Evercare At-home) and the Florida Nursing Home Diversion (Evercare Health and Home Connections) programs. UnitedHealth Group operates eight businesses in Florida with nearly 3,000 employees, 3,000+ contractors, more than 32,000 physicians under contract and serving more than 2.4 million individuals. UnitedHealth Group maintains an established network of 320 hospitals, nursing homes, and durable medical equipment providers in Florida. HCR Manor Care Services of Florida, Inc. (CON #9961) is a newly formed non-profit Florida corporation and, as such, does not have a hospice licensure history.

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HCR Manor Care Services of Florida, Inc. is affiliated with 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. 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. The applicant did not provide copies of its hospice surveys from other states to support its claims. LifePath Hospice & Palliative Care, Inc. (CON #9962) is accredited by JCAHO according to the applicant. Agency records indicate that for the past 36 months the applicant’s affiliate programs in Florida have had no confirmed complaints. Odyssey HealthCare of Manatee County, Inc. (CON #9963) is a newly formed entity and therefore does not have a licensure history in Florida. According to the applicant, Odyssey HealthCare is one of the largest providers of hospice are in United States. Odyssey has 82 Medicare-certified hospice programs in 30 states, with an average daily census of over 8,300 patients. The applicant states that all Odyssey programs are fully licensed and in good standing with state and federal regulators. However, the applicant did not offer federal survey’s of its existing licensed hospice programs so that a comparison could be made between its programs and those licensed in Florida. Agency records indicate that for the past 36 months the applicant’s two affiliate programs in Florida had no confirmed complaints. The Hospice of the Florida Suncoast, Inc. (CON #9964) states that it had developed software to improve availability and accessibility of clinical data, promote patient safety and improve patient outcomes. This product is now utilized by 150+ hospices nationwide. The governing board recently signed off on the organization’s commitment to participate in NHPCO’s new quality partners program. Agency records indicate that for the last 36 months there has been one confirmed complaint without deficiency for the applicant.

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Samaritan Care Hospice of Manatee, Inc. (CON #9972) a wholly owned entity of Samaritan Care Hospice, LLC, is a newly formed corporation. Samaritan Care Hospice in turn was organized to consolidate all of the hospice care activities of Fundamental Long Term Care Holdings, LLC a diversified provider of post-acute and other long-term care, including skilled nursing home care, ALF care, and long-term acute care in addition to hospice services. Samaritan Care Hospice owns, or manages, through various operating entities, a total of nine licensed and fully certified hospices in five states. Four of these are relatively new operations and are in various stages of start-up activities. An additional program is newly licensed and has just begun to accept patients. The other six are more mature, including Hospice of Orange-Osceola, which has been providing care in Hospice Service Area 7B for more than a decade. Agency records indicate that for the past 36 months the applicant’s Florida program had no confirmed complaints. The applicant states that it will seek JCAHO accreditation at the earliest appropriate time if awarded the CON.

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.

Evercare Hospice of Manatee County, Inc. (CON #9960): 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 with no assets and a liability (due to parent) of $20,910 as of November 30, 2006. The applicant’s ultimate parent company is UnitedHealth Group, Inc. (parent). The applicant did not provide a copy of the audited financial statements of the parent company; however, the parent company is a publicly traded corporation and we were able to obtain a copy of the parent’s audited financial statements from the Securities and Exchange Commission’s website. UnitedHealth Group, Inc. will provide funding for this project. Therefore, the audited financial statements of the parent for the periods ending December 31, 2004 and 2005 were analyzed for the purpose of evaluating the parent’s ability to provide the capital and operational funding necessary to implement the project.

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Short-Term Position: The parent’s current ratio of 0.6 indicates current assets are less than current liabilities and results in negative working capital amount of $6 billion, a weak position. The ratio of cash flow to current liabilities of 0.3 is below average and a weak position. Overall, the parent has a weak short-term position. (See table below). Long-Term Position: The long-term debt to equity ratio of 0.4 indicates long-term net assets exceed long-term liabilities. This is below average and a good position. The cash flow to assets ratio of 10.5 percent is slightly above average and an adequate position. The most recent year had revenues in excess of expenses in the amount of $5.1 billion, which resulted in an 11.3 percent operating margin. Overall, the applicant has a good long-term position. (See table below).

UNITED HEALTH GROUP, INC. 12/31/2005 12/31/2004 Current Assets $10,640,000,000 $8,241,000,000

Cash and Current Investment $6,011,000,000 $4,505,000,000

Total Assets $41,374,000,000 $27,879,000,000

Current Liabilities $16,644,000,000 $11,329,000,000

Total Liabilities $23,641,000,000 $17,162,000,000

Net Assets $17,733,000,000 $10,717,000,000

Total Revenues $45,365,000,000 $37,218,000,000

Interest Expense $241,000,000 $128,000,000

Excess of Revenues Over Expenses $5,132,000,000 $4,101,000,000

Cash Flow from Operations $4,326,000,000 $4,135,000,000

Working Capital ($6,004,000,000) ($3,088,000,000)

FINANCIAL RATIOS 12/31/2005 12/31/2004 Current Ratio (CA/CL) 0.6 0.7

Cash Flow to Current Liabilities (CFO/CL) 0.3 0.4

Long-Term Debt to Net Assets (TL-CL/NA) 0.4 0.5

Times Interest Earned (NPO+Int/Int) 22.3 33.0

Net Assets to Total Assets (TE/TA) 42.9% 38.4%

Operating Margin (ER/TR) 11.3% 11.0%

Return on Assets (ER/TA) 12.4% 14.7%

Operating Cash Flow to Assets (CFO/TA) 10.5% 14.8%

Capital Requirements: Schedule 2 indicates the only capital project for the applicant is the project under review. The applicant is projecting an operating loss of $566,340 during the first year of this project. In addition, the parent has committed to fund the project in CON #9965 which has a project cost

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$649,450 and a year 1 projected operating loss of $580,900. Funding will be required for working capital until these projects can earn a profit in year two.

Available Capital: As discussed above, the parent corporation will be providing funding for this project. The ratio analysis discussed above indicates that the short-term position of the parent is very weak. The operating cash flow in 2005 was relatively unchanged from the 2004 year; however, the available working capital decreased from a negative $3.1 billion to a negative $6 billion. Although the short-term position of the parent is weak, the long-term position appears to be in good shape. With $4.3 billion in cash flows from operations, $5.1 billion in operating profits, and a debt to equity ratio of 0.4, the parent should be able to acquire long-term debt, if necessary, to meet its current obligations. Staffing: Schedule 6A indicates for year 1 ending 12/31/2008, the applicant forecasts 12.2 FTE’s as follows: administration 6.3 FTEs, physicians one FTE, nursing 3.2 FTEs, ancillary 1.10 FTEs, no FTE was provided for dietary services, and social services 0.6 FTEs. In the second year ending 12/31/2009 the applicant forecasts 22.3 FTE’s as follows: administration 6.5 FTEs, physicians one FTE, nursing10.4 FTEs, ancillary 2.5 FTEs, no FTE was provided for dietary services, and social services 1.9 FTEs. Evercare provides information regarding employee recruitment, retention and scholarship programs in its application14. These materials do not describe or otherwise affirmatively state recruitment mechanisms, practices or guidelines. However, Evercare does list its employee benefits and company recognition plans which include the following: a new employee orientation program and staff development; health, wellness, dental, vision and disability plans; employee stock purchase; 401(k) retirement options; paid time off and holidays; employee assistance program; education reimbursement and adoption assistance. There is also a nursing scholarship grant program, an employee recognition plan (Sages of Clinical Services Award) and a Clinical Recognition Week. Conclusions: Based on the amount of equity the parent corporation can borrow against and the relatively small size of the project, funding for this project should be available as needed.

14 Refer to Section H in Additional Information/Appendices.

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HCR Manor Care Services of Florida, Inc. (CON #9961) is a development stage enterprise formed under Florida law November 13, 2006. The purpose of the Company is to own and operate hospice programs. As of November 30, 2006, the applicant had no assets and $350 in liabilities. HCR Manor Care Services of Florida, Inc. parent and sole stockholder is HCR Home Healthcare and Hospice, Inc. The applicant provided audited financial statements of its ultimate parent, Manor Care, Inc. (parent), a for-profit corporation, for the periods ended December 31, 2005 and 2004. 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 1.2 indicates current assets are slightly more than current obligations, a below average but acceptable position. The working capital (current assets less current liabilities) of $79.0 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.8 is above average position and a good position. Overall the applicant has a good short-term position. (See table below). Long-Term Position: The parent’s long-term debt to net asset ratio of 1.4 indicates that the parent is highly leveraged. The most recent year had $257.7 million in operating income, which resulted in an operating margin of 7.5 percent. Despite the highly leveraged position, the parent was able to obtain a $300 million revolving credit facility. While the results of operations have weakened somewhat from the previous year, overall, the applicant has an adequate long-term position. (See table below).

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MANOR CARE, INC.

12/31/2005 12/31/2004 Current Assets $531,329,000 $540,367,000

Cash and Current Investment $12,293,000 $32,915,000

Assets Restricted for Capital Projects $0 $0

Total Assets $2,339,234,000 $2,350,464,000

Current Liabilities $452,371,000 $402,254,000

Total Liabilities $1,565,511,000 $1,366,305,000

Net Assets $773,723,000 $984,159,000

Total Revenues $3,417,290,000 $2,916,257,000

Interest Expense $41,240,000 $42,420,000

Operating Income (OI) $257,672,000 $254,879,000

Cash Flow from Operations $353,948,000 $329,766,000

Working Capital $78,958,000 $138,113,000









Capital Requirements: Schedule 2 listed capital projects totaling $603,727. The projects include CON #9966. In addition, funding for the working capital for both these projects will also be required. Available Capital: The parent corporation, Manor Care, Inc., will provide funding for all capital projects. The applicant provided a letter dated December 20, 2006, from Manor Care, Inc. committing to provide funding to the applicant for this project and all other capital projects. As discussed above, the parent company has working capital of $79 million and $257.7 million in operating income. In addition, cash flow from operations was $353.9 million. Staffing: Schedule 6A indicates for year 1 ending 12/31/2008, the applicant forecasts 14.87 FTEs as follows: administration 4.58 FTEs, physicians 0.5 FTEs, nursing 5.66 FTEs, no FTEs were provided for ancillary or dietary services, and social services 4.58. In year two ending

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12/31/2009 the applicant forecasts 20.46 FTEs as follows: administration 5.5 FTEs, physicians .05 FTEs, nursing 9.66 FTEs, no FTEs for ancillary and dietary services, and social services 5.25 FTEs. According to the applicant, it is assisted by its parent company, Manor Care in its staffing and recruitment efforts. It utilizes a corporate human resources department to assist local offices. Recruiters are also used from the corporate office’s human resources department to assist with recruitment for administrative and director of nursing positions; along with a corporate partnership with the Job Corps Program. The parent company also provides scholarships and tuition reimbursement for job related education, including nursing and LPN students, for social workers pursuing a master’s degree, for home health aids studying to become LPNs and RNs, and for hospice and palliative care certification. Support for leadership and management development and training, including on-line courses and educational materials. No employee benefit programs are stated. 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. LifePath Hospice & Palliative Care, Inc. (CON #9962): he audited financial statements of the applicant, for the periods ending December 31, 2004 and 2005 were analyzed for the purposes of evaluating the applicant’s ability to provide the capital and operational funding necessary to implement the project. Short-Term Position: The applicant’s current ratio of 1.8 indicates current assets are slightly less than two times current obligations; this is below average and an adequate position. The working capital (current assets less current liabilities) of $15.8 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 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 0.7 indicates the applicant has a moderately high level of long-term debt. This is above average and a moderately weak position but adequate. The ratio of cash flow to assets of 13.8 percent is above average and a good position. The most

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recent year had operating revenues in excess of expenses of $7.2 million, which resulted in an operating margin of 6.1 percent. Overall, the applicant has an adequate long-term position. (See table below).

LIFEPATH HOSPICE & PALLIATIVE CARE, INC. 12/31/2005 12/31/2004 Current Assets $35,621,738 $24,909,081


Assets Limited as to Use $8,461,406 $7,882,025

Total Assets $98,882,862 $82,792,190


Total Liabilities $53,240,112 $47,149,569

Net Assets $45,642,750 $35,642,621

Total Revenues $117,423,216 $95,997,291

Interest Expense $980,304 $224,470



Working Capital $15,807,554 $12,327,219









Capital Requirements: Schedule 2 indicates the applicant has capital projects and long-term debt totaling $12.9 million. Available Capital: Funding for this project will come from income from operations and cash on hand. As discussed above working capital is $15.9 million, and cash flows from operations were $13.7 million is 2005. In addition, the audit indicates the applicant has access to a $3 million line of credit. Staffing: Schedule 6A indicates for year 1, the applicant forecasts 21.76 FTEs as follows: patient family counselor 1.5 FTE, HospiceHelp 24 .10 FTE, PFC consultant .04 FTE, chaplain 0.5 FTEs, HospiceHelp 24 0.1 FTE, chaplain consultant .04 FTE, RN’s with replacement 4.2 FTE’s, home health aide with replacement 3.48 FTE, administration including

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receptionist, site secretary, administrator, medical director, ARNP, 3.98 FTEs, admissions RN’s 1.79 FTEs, volunteer coordinator 0.52 FTEs, bereavement counselor 1.42 FTEs, continuous care 1.17 FTEs, and pharmacist 1.0 FTE. There was no FTE provided for dietary services. In year two the applicant forecasts 29.64 FTE’s as follows: patient family counselor 1.88 FTEs, chaplain 0.84 FTE’s, RN’s 6.53 FTEs, home health aide 5.54 FTEs, administration 4.25 FTEs, admissions RN 2.16 FTEs, hospice representative 2.34 FTEs, volunteer coordinator 0.52 FTEs, bereavement counselor 1.56 FTEs, continuous care 2.47 FTEs, and pharmacist 1.55 FTEs. LifePath refers to schedule 6 to identify projected staff for the proposed hospice. The applicant further states that staff will be recruited and trained from local communities where ever possible to take advantage of local knowledge and relationships. The same corporate staff that manages hospice operations in Service Areas 6A and 6B will manage the development of the proposed hospices services in Service Area 6C. The applicant does not reference an employee benefit plan. No further information is provided regarding recruitment or retention of staff. Conclusion: Funding for this project and all capital projects should be available as needed. Odyssey HealthCare of Manatee County, Inc. (CON #9963) was formed as a for-profit corporation in Delaware on October 18, 2006. The purpose of the Company is to own and operate hospice programs. As of October 31, 2006, the applicant had no assets or liabilities. The applicant provided audited financial statements of its parent and sole stockholder, Odyssey Healthcare, Inc. (parent), a for-profit corporation, for the periods ended December 31, 2005 and 2004. 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 1.9 indicates current assets are slightly less than two times current obligations; this is slightly below average and an adequate position. The working capital (current assets less current liabilities) of $61.6 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.9 is an above average and a good position. Overall the applicant has a good short-term position. (See table below). Long-Term Position:

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The parent’s long-term debt to net asset ratio of 0.1 indicates the parent has minimal long-term liabilities when compared to net assets, a good position. The most recent year had $31.8 million in operating income, which resulted in an operating margin of 8.3 percent. The operating results were down from the prior year; however, the 2005 year operating results includes a $13 million expense allocation of a settlement with the Department of Justice. Overall, the parent has a good long-term position. (See table below).

ODYSSEY HEALTHCARE, INC. 12/31/2005 12/31/2004 Current Assets $130,338,000 $98,166,000


Assets Restricted for Capital Projects $0 $0

Total Assets $244,967,000 $204,091,000



Net Assets $167,298,000 $162,080,000

Total Revenues $381,649,000 $350,276,000

Interest Expense $198,000 $118,000



Working Capital $61,617,000 $63,259,000









Capital Requirements: Schedule 2 listed capital projects totaling $3,425,590. The parent corporation, Odyssey Healthcare, Inc., will provide funding for all capital projects. The applicant provided a letter dated December 21, 2006, from Odyssey Healthcare, Inc. committing to provide funding and working capital to the applicant for this project and all other capital

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projects. As discussed above, the parent company has working capital of $6.6 million and $31.8 million in operating income. In addition, cash flow from operations was $58.7 million. Staffing: Schedule 6A indicates for year 1 ending 08/31/2008, the applicant forecasts 11.9 FTEs as follows: administration 7.0 FTEs, physicians 0 FTE, nursing 3.6 FTEs, ancillary 0.4 FTEs, dietary 0.3 FTEs, social services 0.6 FTEs. In year two ending 8/31/09, the applicant forecasts 27.8 FTEs as follows: administration 10.0 FTEs, physicians 0 FTE, nursing 12.6 FTEs, ancillary 3.2 FTEs, dietary 0.3 FTEs, and social services 1.7 FTEs. Odyssey provides information regarding employee benefits, employee certification programs, and tuition assistance programs. The employee benefits are listed as follows: major medical insurance, prescription drug program, dental insurance, vision, flexible spending accounts, long term disability, optional life insurance, 401 (K), and employee stock purchasing plan. The certification programs are for: RN certification, LPN/LVN certification, CNA/HHA certification as well as a tuition assistance program. Briefly stated, Odyssey recruits staff for its hospices from the local community, no further information regarding recruitment was provided. 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. The Hospice of the Florida Suncoast, Inc. (CON #9964): The audited financial statements of the applicant, for the periods ending September 30, 2004 and 2005 were analyzed for the purpose of evaluating the applicant’s ability to provide the capital and operational funding necessary to implement the project. Short-Term Position: The applicant’s current ratio of 1.5 indicates current assets are one and a half times current obligations; this is below average and an adequate position. The working capital (current assets less current liabilities) of $9 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.1 is well below average and a weak position. The audit shows a significant improvement in the short-term position over the prior year. This

79


improvement appears to be the result of paying off $6.5 million in short-term obligations with a recent bond issue. Overall the applicant has a slightly weak but adequate short-term position. (See table below). Long-Term Position: The ratio of long-term debt to net assets of 0.2 indicates the applicant has a low level of long-term debt relative to net assets despite the issuance of $21.4 million in tax-exempt bonds in December of 2004. This indicates the applicant has sufficient equity to acquire more long-term debt if necessary. This is well below average and a strong position. The ratio of cash flow to assets of 2.7 percent is well below average and a weak position. The most recent year had operating revenues in excess of expenses of $99,494, which resulted in an operating margin of 0.1 percent. Overall, the applicant has an adequate long-term position. (See table below).

THE HOSPICE OF THE FLORIDA SUNCOAST, INC. 9/30/2005 9/30/2004 Current Assets $27,961,083 $24,665,752


Beneficial Interest in Hospice Foundation $28,194,719 $25,517,442

Total Assets $86,139,320 $72,627,071



Net Assets $53,890,924 $47,270,322

Total Revenues $92,815,661 $86,350,976

Operating Income (OI) $99,494 $374,816

Cash Flow from Operations $2,324,909 ($172,272)

Working Capital $8,984,427 ($530,671)







Operating Cash Flow to Assets (CFO/TA) 2.7% -0.2%

Capital Requirements: Schedule 2 indicates the applicant has capital projects totaling $13.3 million. This schedule does not appear to include maturities on long-term debt of $474,233 in 2008. In addition, the applicant is projecting operating losses in years one and two.

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Available Capital: Funding for this project and all capital projects will come from income from operations, cash on hand, and the related party hospice foundation. According to the audit, the foundation’s purpose is to obtain, hold, and manage funds to be used for the benefit of the applicant. The applicant’s beneficial interest in the foundation as of September 30, 2005, was $28.2 million. As discussed above working capital is $9 million, and cash flows from operations were $2.3 million is 2005. Staffing: Schedule 6A indicates for year 1 ending 06/30/2008, the applicant forecasts 32.9 FTEs as follows: administration 5.5 FTEs, physicians 0.8 FTEs, nursing 17.9 FTEs, ancillary 2.4 FTEs, dietary 0.2 FTEs, social services 4.7 FTEs, and plant maintenance 1.5 FTEs. In year two ending 6/30/2008 the applicant forecasts 44.4 FTEs as follows: administration 5.5 FTEs, physician 1.0 FTEs, nursing 27.0 FTEs, ancillary 2.6 FTEs, dietary 0.2 FTEs, social services 6.6 FTEs, and plant maintenance 1.5 FTEs. Suncoast proposes to utilize current staff who live in Manatee County and to recruit the necessary staff to support the proposed project. However, the applicant does not give further detail regarding its recruitment practices. No further information was provided by the applicant regarding employee retention, benefit packages or certification programs. Conclusion: Based on the financial position of the applicant and support from the foundation, funding for this project and all capital projects should be available as needed. Samaritan Care Hospice of Manatee, Inc. (CON #9972) is a for-profit development stage company incorporated on October 20, 2006. An audit of the development stage company revealed total liabilities of $95,809. Because this applicant is a development stage company and the applicant did not provide audited financial statements of its parent company, the applicant’s financial position cannot be determined. Capital Requirements: Schedule 2 indicates that the only project planned is the initiation of a hospice program in Manatee County which is the subject of this application. The total cost of this project is $415,087. It should be noted that the applicant is projecting an operating loss of $319,430

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during the first year of this project and anticipates turning a profit in the fifth month of year 2 Funding for working capital will also be required for this project until a profit can be reached in year two. Available Capital: The applicant indicated, and it is supported by the audit, that $37,122 has already been acquired from the parent company and spent on the CON application process. The applicant provided a letter dated December 21, 2006, from Capital Source Finance, LLC (Capital Source) indicating that it is anticipated that the applicant would be added to an amended and restated revolving credit and security agreement. The letter indicates Capital Source is confident that as a borrower, the applicant will have the necessary funds available under the agreement for start-up and working capital. A subsequent event note in the audit indicates that on December 22, 2006, Capital Source committed to add the applicant as a borrower under the parent’s revolving credit agreement. Although no information was provided on the parent company, it appears that credit has already been extended to the parent and that the lender believes the credit available is sufficient to fund start-up and working capital for this project. Staffing: Schedule 6A indicates for year 1, the applicant forecasts 22.5 FTEs as follows: administration 5.0 FTEs, physician one contract, nursing 11.5 FTEs, ancillary three contract and two FTEs, no dietary FTE, and social services 4.0. In year two the applicant forecasts the following: administration nine FTEs, physicians one contract, nursing 22.0 FTEs, ancillary three contract and 4.0 FTEs, no dietary FTE, and social services 8.0 FTEs. Samaritan does not provide any information regarding employee recruitment, employee retention, or employee benefits. The applicant briefly states that the proposed project will require recruitment of a complete team and support staff but does not provide any further explanation. Conclusion: Assuming the applicant will be added to its parent’s credit agreement as indicated by the lender, funding for this project should be available as needed.

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

proposal? ss. 408.035 (8), Florida Statutes.

EverCare Hospice of Manatee County, Inc. (CON #9960): Schedule 7 of the application indicates that the services to be provided are: routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are: Medicare at 96.0 percent, Medicaid at 1.0 percent, self-payers/charity at 2.0 percent, and commercial insurance/managed care at 1.0 percent. 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 the Manatee County, Florida wage index for Medicare Hospice payments of 1.0251 and inflated through December 2009. The average price adjustment factor used was 3.49 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2006 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year 2 were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that level of patient days. The results were then compared to the applicant’s estimated revenue. The applicant appears to have understated revenues by approximately 7.0 percent. When the projected deduction for charity and bad debt are considered ($52,047) the understatement is 4.7 percent. Understating revenues is a conservative approach to financial projections. The results of the calculations are summarized in the table below. A review of the projected expenses indicates that expenses in year 1 and two are consistent with the applicant’s assumptions. The applicant projects an operating profit of $114,912 by the end of year two. Conclusion: This project appears to be financially feasible.

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HOSPICE REVENUE CON #9960 Evercare Hospice of Manatee County, Inc. Wage Index for Sarasota and Manatee County (1.0251)

Wage

Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $89.87 1.0251 $92.13 $40.92 $133.05 Continuous Home Care $524.50 1.0251 $537.66 $238.86 $776.52 Inpatient Respite $73.24 1.0251 $75.08 $62.06 $137.14 General Inpatient $372.42 1.0251 $381.77 $209.40 $591.17

Payment

Rate

Inflation Factor

Year Two

Inflation Adjusted Amount

Patient Days Year 2, Dec

2009 Extended Routine Home Care $133.05 1.114 $148.15 16,512 $2,446,271 Continuous Home Care $776.52 1.114 $864.69 170 $146,997 Inpatient Respite $137.14 1.114 $152.71 170 $25,960 General Inpatient $591.17 1.114 $658.29 170 $111,909 Total 17,022 $2,731,137 From Schedule 7 $2,550,325 Difference ($180,812) Percentage Difference -7.09% Charity & Bad Debt $52,047 Perct. Diff incl. Charity -4.71% HCR Manor Care Services of Florida, Inc. (CON #9961): Schedule 7 of the application indicates that the services to be provided are: routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are: Medicare at 72.0 percent, Medicaid at 22.0 percent, self-payers at 1.0 percent, charity at 2.0 percent, and commercial insurance at 3.0 percent. 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 the Manatee County, Florida wage index for Medicare Hospice payments of 1.0251 and inflated through December 2009. The average price adjustment factor used was 3.49 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2006 Health Care Cost Review. Estimated revenues for each level of service from Schedule 7, year 2 were divided by the calculated reimbursement rate for that service in order to estimate the total patient days that would be generated by that level of

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revenue. The results were then compared to the applicant’s estimated number of patient days. The results of the calculations are summarized in the table below.

The applicant’s projected patient days were 4.06 percent or 726 days greater than the calculated patient days. The applicant used an inflation factor consistent with the market basket factor of 3.49 percent. The applicant’s projected revenues appear to be understated. Understating revenues is a conservative approach to financial projections. A review of the projected expenses indicates that expenses in year 1 and two are consistent with the applicant’s assumptions. The applicant projects an operating profit of $700,600 by the end of year two. Conclusion: This project appears to be financially feasible. HOSPICE REVENUE CON #9961 HCR Manor Care Services of Florida, Inc. Wage Index for Sarasota and Manatee County (1.0251)

Wage


Adjusted Wage


Payment Rate


Payment

Rate

Inflation Factor

Year Two


Gross Rev. Year 2, Dec

2009

Calculated Patient Days

Routine Home Care $133.05 1.114 $148.15 $2,445,200

16,505 Continuous Home Care $776.52 1.114 $864.69 $59,200 68 Inpatient Respite $137.14 1.114 $152.71 $8,000 52 General Inpatient $591.17 1.114 $658.29 $338,700 515

Total $2,851,100

17,140

From Schedule 7

17,866 Difference 726 Percentage difference 4.06% LifePath Hospice & Palliative Care, Inc. (CON #9962): Schedule 7 of the application indicates that the services to be provided are: routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are: Medicare at 88.0 percent, Medicaid at 6.0 percent, self-payers/charity at 3.3 percent, and commercial insurance at 2.7 percent. 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 the Manatee County, Florida wage index for Medicare Hospice payments of 1.0251 and inflated through June 2009. The average price adjustment factor

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used was 3.54 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2006 Health Care Cost Review. Estimated patient days for each level of service from Schedule 7, year 2 were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that level of patient days. The results were then compared to the applicant’s estimated gross revenue. The applicant appears to have understated gross revenues by approximately 5.7 percent. Understating revenues is a conservative approach to financial projections. The results of the calculations are summarized in the table below.

A review of the projected expenses indicates that expenses in year 1 and two are consistent with the applicant’s assumptions. The applicant projects an operating profit of $282,114 by the end of year two. Conclusion: This project appears to be financially feasible. HOSPICE REVENUE CON #9962 LifePath Hospice & Palliative Care, Inc. Wage Index for Sarasota and Manatee County (1.0251)

Wage


Adjusted Wage


Payment Rate


Payment

Rate

Inflation Factor

Year Two


Patient Days Year 2, June

2009 Extended Routine Home Care $133.05 1.097 $146.01 23,809 $3,476,332 Continuous Home Care $776.52 1.097 $852.19 330 $281,222 Inpatient Respite $137.14 1.097 $150.50 27 $4,064 General Inpatient $591.17 1.097 $648.77 1,464 $949,797 Total 25,630 $4,711,415 From Schedule 7 $4,459,298 Difference ($252,117) Percentage Difference -5.65% Odyssey HealthCare of Manatee County, Inc. (CON #9963): Schedule 7 of the application indicates that the services to be provided are: routine home care, continuous home care, respite and general inpatient care. The payer types identified in the application as a percentage to total patient days are: Medicare at 95.0 percent, Medicaid at 3.0 percent, charity at 1.0 percent, and commercial insurance at 1.0 percent. 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 the Manatee

86


County, Florida wage index for Medicare Hospice payments of 1.0251 and inflated through August 2009. The average price adjustment factor used was 3.52 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2006 Health Care Cost Review. Estimated revenues for each level of service from Schedule 7, year 2 were divided by the calculated reimbursement rate for that service in order to estimate the total patient days that would be generated by that level of revenue. The results were then compared to the applicant’s estimated number of patient days. The results of the calculations are summarized in the table below.

The applicant’s projected patient days were 4.95 percent or 812 days greater than the calculated patient days. The applicant used an inflation factor of two percent which is less than the market basket factor of 3.52 percent. Therefore, the applicant’s projected revenues were understated. Understating revenues is a conservative approach to financial projections. When the two percent inflation factor is used, the difference in patient days is 1.06 percent and is not considered material. A review of the projected expenses indicates that expenses in year 1 and two are consistent with the applicant’s assumptions. The applicant projects an operating profit of $17,783 by the end of year two. Conclusion: This project appears to be financially feasible. HOSPICE REVENUE CON #9963 Odyssey Healthcare of Manatee County, Inc. Wage Index for Sarasota and Manatee County (1.0251)

Wage


Adjusted Wage


Payment Rate


Payment

Rate

Inflation Factor

Year Two


Gross Rev. Year 2, Aug

2009


Routine Home Care $133.05 1.103 $146.72 $2,195,633 14,964 Continuous Home Care $776.52 1.103 $856.35 $178,063 208 Inpatient Respite $137.14 1.103 $151.24 $31,424 208 General Inpatient $591.17 1.103 $651.94 $135,410 208 Total $2,540,530 15,588 From Schedule 7 16,400 Difference 812 Percentage difference 4.95% The Hospice of the Florida Suncoast, Inc. (CON #9964): Schedule 7 of the application indicates that the services to be provided are: routine home care, continuous home care, respite and general inpatient care.

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The payer types identified in the application as a percentage to total patient days are: Medicare at 85.0 percent, Medicaid at 6.0 percent, self-payers/charity at 5.0 percent, and commercial insurance at 4.0 percent. 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 the Manatee County, Florida wage index for Medicare Hospice payments of 1.0251 and inflated through June 2009. The average price adjustment factor used was 3.54 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2006 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 level of patient days. The results were then compared to the applicant’s estimated gross revenue. The applicant appears to have understated gross revenues by approximately 13.4 percent or $630,975. A closer analysis reveals that the applicant used $18 per patient day for respite care and $466 per patient day for continuous care. These amounts are well below the current payment rates of $137 and $777 for respite and continuous care respectively (before inflation adjustments). Schedule 7 listed “other” as a level of care category with total revenues of $266,159 that was not used in the gross revenue analysis in the table below. The applicant did not explain what this revenue represented even though the notes to Schedule 7 indicate that the patient service revenue was based on the four standard reimbursement categories. Even if this revenue were included in the analysis, the projected revenue would still be understated. Understating revenues is a conservative approach to financial projections. The results of the calculations are summarized in the table below. A review of the projected expenses indicates that expenses in year 1 and two are consistent with the applicant’s assumptions. The applicant projects an operating loss of $269,689 by the end of year two. Based on the audit of the applicant, the applicant’s margin is relatively thin and if needed would rely on the foundation to support its operations. The combined projected operating margin with the applicant’s existing hospice programs is projected to approximately break even in year two. This is consistent with the applicant’s actual operations as indicated in the September 30, 2004 and 2005, audited financial statements. Conclusion: With the support of the foundation, this project appears to be financially feasible.

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HOSPICE REVENUE CON #9964 The Hospice of the Florida Suncoast, Inc. Wage Index for Sarasota and Manatee County (1.0251)

Wage


Adjusted Wage

Amount Unadjusted Component Payment Rate


Payment

Rate

Inflation Factor

Year Two


Patient Days Year 2, June

2009 Extended Routine Home Care $133.05 1.097 $146.01 31,181 $4,552,712 Continuous Home Care $776.52 1.097 $852.19 244 $207,933 Inpatient Respite $137.14 1.097 $150.50 244 $36,722 General Inpatient $591.17 1.097 $648.77 812 $526,800 Total 32,481 $5,324,168 From Schedule 7 $4,693,193 Difference ($630,975) Percentage Difference -13.44% Samaritan Care Hospice of Manatee, Inc. (CON #9972): Schedule 7 of the application indicates that the services to be provided are: routine home care and general inpatient care. The payer types identified in the application as a percentage to total patient days are: Medicare at 82.0 percent, Medicaid at 8.0 percent, self-pay/charity at 5.0 percent, and commercial insurance at 5.0 percent. 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 the Manatee County, Florida wage index for Medicare Hospice payments of 1.0251 and inflated through December 2009. The average price adjustment factor used was 3.49 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2006 Health Care Cost Review. Estimated revenues for each level of service from Schedule 7, year 2 were divided by the calculated reimbursement rate for that service in order to estimate the total patient days that would be generated by that level of revenue. The results were then compared to the applicant’s estimated number of patient days. The results of the calculations are summarized in the table below.

The applicant’s projected patient days were 0.99 percent or 230 days greater than the calculated patient days. The applicant used an inflation factor of 3.0 percent which is slightly less than the market basket factor of 3.49 percent. The difference in patient days is not considered material and is likely due to the lower inflation rate used by the applicant. A review of the projected expenses indicates that salary expenses in year 1

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may have been understated based on the information in Schedule 6, the year two expenses appear consistent with the applicant’s assumptions. The applicant projects an operating profit of $191,332 by the end of year two. Conclusion: This project appears to be financially feasible. HOSPICE REVENUE CON #9972 Samaritan Care Hospice of Manatee, Inc. Wage Index for Sarasota and Manatee County (1.0251)

Wage


Adjusted Wage


Payment Rate


Payment

Rate

Inflation Factor

Year Two


Gross Rev. Year 2, Dec

2009


Routine Home Care $133.05 1.114 $148.15 $3,392,772 22,901 Continuous Home Care $776.52 1.114 $864.69 $0 - Inpatient Respite $137.14 1.114 $152.71 $0 - General Inpatient $591.17 1.114 $658.29 $89,079 135 Total $3,481,851 23,036 From Schedule 7 23,266 Difference 230 Percentage difference 0.99%

e. Will the proposed project foster competition to promote quality and cost-effectiveness? ss. 408.035(7), Florida Statutes. Each co-batched applicant is applying for a new hospice program to be located in Hospice Service Area 6C that currently has only one existing hospice program. Therefore, each co-batched applicant is offering a new choice of provider in the hospice service area.

The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans.

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

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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. Evercare Hospice of Manatee County, Inc. (CON #9960) is proposing a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice program. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting 1.0 percent of patient days from managed care payers with 97.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid).

With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the only existing hospice provider in the service area. This project would introduce competition to the market, and with price based competition not at issue, the focus would likely be placed on quality of care and public awareness/advertising as a means of the two providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Although this project is not likely to result in price based competition, if approved, this project will add a competitor to a service area in which there is only one provider. The addition of a new provider in a monopoly market by definition introduces competition. The introduction of competition to a market, in general, results in an environment that promotes quality and cost-effectiveness. HCR Manor Care Services of Florida, Inc. (CON #9961) is proposing a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice program. Therefore, this project is offering a new choice of provider in the service area.

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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. The applicant is projecting no patient days from managed care payers with 94.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the only existing hospice provider in the service area. This project would introduce competition to the market, and with price-based competition not at issue, the focus would likely be placed on quality of care and public awareness/advertising as a means of the two providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. This application is for a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice programs. Therefore, this project is offering a new choice of provider in the service area.

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LifePath Hospice & Palliative Care, Inc. (CON #9962) proposes to establish a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice program. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is not projecting any days from managed care payers with 94.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the only existing hospice provider in the service area. This project would introduce competition to the market, and with price-based competition not at issue, the focus would likely be placed on quality of care and public awareness/advertising as a means of the two providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Although this project is not likely to result in price-based competition, if approved, this project will add a competitor to a service area in which there is only one provider. The addition of a new provider in a monopoly market by definition introduces competition. The introduction of competition to a market, in general, results in an environment that promotes quality and cost-effectiveness. Odyssey HealthCare of Manatee County, Inc. (CON #9963) proposes to establish a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice programs. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price

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for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting no patient days from managed care payers with 98.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the only existing hospice provider in the service area. This project would introduce competition to the market, and with price-based competition not at issue, the focus would likely be placed on quality of care and public awareness/advertising as a means of the two providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Although this project is not likely to result in price-based competition, if approved, this project will add a competitor to a service area in which there is only one provider. The addition of a new provider in a monopoly market by definition introduces competition. The introduction of competition to a market, in general, results in an environment that promotes quality and cost-effectiveness. The Hospice of the Florida Suncoast, Inc. (CON #9964) proposes to establish a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice program. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is not projecting any days from managed care payers with 91.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-

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effectiveness. However, if approved, this applicant would be an alternative to the only existing hospice provider in the service area. This project would introduce competition to the market, and with price-based competition not at issue, the focus would likely be placed on quality of care and public awareness/advertising as a means of the two providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. It should be noted that the applicant indicates in the narrative of the application that it has an existing collaborative relationship with the current provider. To the extent this relationship continues, competition may be limited. Although this project is not likely to result in price-based competition, if approved, this project will add a competitor to a service area in which there is only one provider. The addition of a new provider in a monopoly market by definition introduces competition. The introduction of competition to a market, in general, results in an environment that promotes quality and cost-effectiveness. Samaritan Care Hospice of Manatee, Inc. (CON #9972) proposes to establish a new hospice program to be located in Hospice Service Area 6C which currently has one existing hospice programs. Therefore, this project is offering a new choice of provider in the service area. The impact of the price of services on consumer choice is limited to the payer type. Most consumers do not pay directly for hospice services rather they are covered by a third-party payer. The impact of price competition would be limited to third-party payers that negotiate price for services, namely managed care organizations. Therefore, price competition is limited to the share of patient days that are under managed care plans. The applicant is projecting no patient days from managed care payers with 90.0 percent of patient days expected to come from fixed price government payer sources (Medicare and Medicaid). With the large majority of patient care being provided from fixed price government payer sources, this project is not likely to have any discernable positive impact on price-based competition to promote cost-effectiveness. However, if approved, this applicant would be an alternative to the only existing hospice provider in the service area. This project would introduce competition to the market, and with price-based competition not at issue, the focus would likely be placed on quality of

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care and public awareness/advertising as a means of the two providers to differentiate themselves from one another. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost-effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services to be provided for the same Federal and State dollars. Although this project is not likely to result in price-based competition, if approved, this project will add a competitor to a service area in which there is only one provider. The addition of a new provider in a monopoly market by definition introduces competition. The introduction of competition to a market, in general, results in an environment that promotes quality and cost-effectiveness.

f. Are the proposed costs and methods of construction reasonable? Do they comply with statutory and rule requirements? ss. 408.035(8), Florida Statutes and Ch. 59A-3 or 59A-4, Florida Administrative Code.

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(11), Florida Statutes.

Evercare Hospice of Manatee County, Inc. (CON #9960) states that it accepts all patients without regard to gender, national origin, race, creed, sexual orientation, disability, age, and place of residence or ability to pay. The applicant states that approximately 34.5 percent of Evercare Hospice & Palliative Care’s FY 2005 non-Medicare net revenue is Medicaid. Approximately one percent of services are provided to indigent/charity patients. Schedule 7A shows $13,045 for charity care in year 1, and $39,036 for charity care in year two. Evercare’s patient day Medicaid percentage is projected at as 7.9 percent. HCR Manor Care Services of Florida, Inc. (CON #9961) is a new entity and has no history of providing Medicaid services.

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Schedule 7A shows charity care in year 1 $32,200 and $57,100 in year two. HCR Manor Care’s patient day Medicaid percentage is projected at 22 percent. LifePath Hospice & Palliative Care, Inc. (CON #9962) has a history of providing services to all persons regardless of ability to pay, including Medicaid patients and the medically indigent. According to the applicant, in 2006, more than six percent of all patient days were provided to Medicaid or medically indigent patients. Schedule 7A does not have a stipulation for charity care. LifePath’s patient day Medicaid percentage is projected at six percent. Odyssey HealthCare of Manatee County, Inc. (CON #9963) is a new entity and has no history of service to Medicaid and Medically indigent patients. According to the applicant, approximately 60 percent of Odyssey’s Healthcare, Inc.’s YTD November 2006 non-Medicare net revenue is Medicaid. Further, approximately two percent of services provided are delivered to indigent and charity patients. Schedule 7A shows charity care at $15,022 in year 1 and $47,863 in year two. Odyssey’s patient day Medicaid percentage is projected at three percent. The Hospice of the Florida Suncoast, Inc. (CON #9964) states that during 2006, a total of five percent of Suncoast’s patient days were Medicaid and five percent were un-reimbursed charity care. Suncoast provided a total of $11,500,000 in uncompensated care to the community during fiscal year 2006. In addition, the applicant indicates that The Hospice of the Florida Suncoast, Inc. provides a variety of community and counseling services for which no revenue is recognized or received. These include residential hospice care, children and family community services, bereavement support, palliative care initiatives, and community education. These services offered are part of the organizations charitable purpose and are not included in the charity care revenue deductions shown on Schedule 7A. Schedule 7A shows $0.00 for charity care in year 1, and $0.00 for charity care in year 2. Suncoast’s patient day Medicaid percentage is projected at six percent. Samaritan Care Hospice of Manatee, Inc. (CON #9972) states that its related Florida hospice provider, Hospice of Orange-Osceola, currently provides approximately eight percent of its total patient care to Medicaid patients, and approximately three percent to indigent patients.

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Samaritan has a similar payer mix and is reflected in our financial projections, specifically in Schedules 7A and 8A. Schedule 7A shows $23,902 for charity care in year 1, and $63,036 in year two. Samaritan’s patient day Medicaid percentage is projected at 7.9 percent.

F. SUMMARY A fixed need pool was published for a new hospice program in Hospice Service Area 6C, Manatee County. Evercare Hospice of Manatee County, Inc. (CON #9960) proposes the establishment of a new hospice program in Hospice Service Area 6C, Manatee County. The project cost totals $649,450 and year two operating costs of $2,435,413. The project does not involve any construction costs. Evercare proposes to condition award of the CON on the following: it will provide non-covered services such as but not limited to therapies (music, massage, aroma, and other holistic treatments. HCR Manor Care Services of Florida, Inc. (CON #9961) proposes to establish a new hospice program in Hospice Service Area 6C, Manatee County. The project cost totals $297,956 and year two operating costs of $3,067,900. The project does not involve any construction costs. The applicant has not agreed that any measurable condition be placed on the CON. Rather it has stated that it will serve anyone seeking services as required by state and federal regulations for hospice services and if the state places a condition on the CON, it will annually report on that condition. LifePath Hospice & Palliative Care, Inc. (CON #9962) proposes to establish a new hospice program in Hospice Service Area 6C, Manatee County. The project cost total $383,773 and year two operating costs of $5,277,500. This project does not involve any construction costs. The applicant has agreed to conduct education and outreach programs in Manatee County aimed at enhancing access, if awarded the CON. The applicant did not offer any way to measure this commitment. Odyssey HealthCare of Manatee County, Inc. (CON #9963) proposes to establish a new hospice program in Hospice Service Area 6C, Manatee County. The project cost totals $464,720 and year two operating costs of $2,468,413. The project does not involve any construction costs. The applicant also agrees to condition award of the CON upon providing non-

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covered services, such as, but not limited to: therapies (music, massage, aroma, and other holistic treatments). The applicant will spend at least $25,000 during the first two years of operation to provide or fund public education programs dealing with end-of-life planning. The Hospice of the Florida Suncoast, Inc. (CON #9964) proposes to establish a new hospice program in Hospice Service Area 6C, Manatee County. The project cost totals $228,225 and year two operating costs of $4,980,035. The applicant states that it is willing to condition award of the CON upon the following: 1. Commitment of $250,000 annually for the first two years of


2. The commitment of 0.5 FTE the first year of operation for the development efforts of a children’s hospice program in the Manatee County communities.

3. The commitment of 0.5 FTE in the first year of operation for the development efforts for community bereavement programs in the Manatee County communities.

4. The commitment of one FTE to be operationalized the first year for the provision of caregiver services to hospice patients. The provision of caregiver services will be provided up to an amount of $33,750 (an estimated cost of $2.23 per day for a five-year period).

5. 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 special outreach to Hispanic children.

6. The provision of three FTEs to allow for uninterrupted 24-hour care seven days a week to be dedicated to evening and weekend services whose sole responsibility and oversight is that of evening and weekend care.

7. Provision of an AIDS program that will collaborate with existing AIDS Service Organizations in Manatee County in meeting the needs of hospice patients with HIV.

8. The development in one year of a community resource library. This library will include various lay and professional education pieces related to chronic illness, death, dying and bereavement.

9. Within the first two years hire a full-time physician who will develop physician services including palliative care consults within area hospitals, nursing homes and the community.

10. The implementation of a teen volunteer program within the first two years of operation.

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11. The expansion in year 1 of The Hospice of the Florida Suncoast’s current children’s and family retreat programs to the residents of Manatee County.

12. Beginning in year 1, a minimum budget of $1,200 per interdisciplinary team for the provision of special wish funds for hospice patients and families.

13. The development, in year 1, of a minimum of one community advisory committee to be composed of residents reflective of the community whose purpose is to provide input and feedback about the needs of the Manatee County community and whose recommendations will be used in the future program development.

14. In year 1, the formation of a Manatee Council of Hospice Ambassadors to lead fundraising efforts on behalf of The Hospice of the Florida Suncoast in Manatee County.

Samaritan Care Hospice of Manatee, Inc. (CON #9972) proposes to establish a new hospice program in Hospice Service Area 6C, Manatee County. The project cost totals $415,087 and year two operating costs of $3,227,483. The project does not involve any construction costs. The applicant states that it does not wish to accept any conditions placed upon the CON, should it be awarded. Need/Access: Each applicant is responding to published need for a new hospice program. Odyssey claims that projected need would allow the establishment of two new programs, however it did not evidence any special circumstances and therefore need for a second program was not demonstrated. Although each applicant states that there is unmet need in Manatee County, which ranged from low utilization rates for select years that were not consistently demonstrated, perceived short lengths of stay, undocumented claims of lengthy admission times, to undocumented access issues for minority populations including Hispanic and African-Americans, no access issues or unmet need was demonstrated by any applicant. HCR Manor Care indicated that it believes that it has distinguished itself and identified an unmet need in the area, which would be solved by targeting patients who want to receive curative treatment. This applicant states that it conducted an information survey of the existing provider and all co-batched applicant and none were offering curative care or planed to offer curative care. Despite HCR Manor Care’s survey in which it states on other applicant would offer this care to patients, Evercare states that it would offer aggressive therapies, suggesting curative care. It

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is noted that hospice is defined in Florida as a provider of palliative care, which is by definition non-curative. Four of the six co-batched applicants provided evidence that they would be able to secure referrals from local providers, HCR Manor Care, LifePath, Suncoast and Samaritan. HCR Manor Care demonstrated its ability to contract for inpatient services from local hospital and nursing homes. Evercare, HCR Manor Care, LifePath and Odyssey offered to condition award of the CON to provide services beyond core services, but Suncoast distinguished itself by agreeing to measurable conditions, if awarded the CON, to ensure that its proposed program offers improved access to hospice care, improved education regarding available hospice services, and to address any cultural barriers to hospice care in Manatee County. Recent changes in hospice licensing law indicate that hospice programs that fail to meet their CON condition without good cause, loose their license. The Agency’s need methodology that resulted in published need for a new program in Manatee County showed the projected number of admissions minus the current number of admissions for the January 2008 planning horizon as 416. Suncoast proposed the largest program to address this published need:

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Co-Batched Applicant

Proposed Admissions Year Two Applicant Proposed Admissions

Evercare CON #9960 340 HCR Manor Care CON #9961 257 LifePath CON #9962 294 or 309 Odyssey CON #9963 328 Suncoast CON #9964 406 Samaritan CON #9972 205 Source: CON applications 9960-9964 and 9972 Quality of Care: Each applicant offered evidence of its ability to provide quality care. Financial Feasibility/Availability of Funds: Evercare Hospice of Manatee County, Inc. (CON #9960): Based on the amount of equity the parent corporation can borrow against and the relatively small size of the project, funding for this project should be available as needed. Overall short-term position is weak but the long-term position is good. HCR Manor Care Services of Florida, Inc. (CON #9961): 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 has a good short-term position and an adequate long-term position. This project appears to be financially feasible assuming the applicant meets its projections. LifePath Hospice & Palliative Care, Inc. (CON #9962): Funding for this project and all capital projects should be available as needed. Overall the applicant has an adequate short-term position as well as an adequate long-term position. This project appears to be financially feasible assuming the applicant meets its projections. Odyssey HealthCare of Manatee County, Inc. (CON #9963): 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 has a good short-term position as well as a good long-term position. This project appears to be financially feasible assuming the applicant meets its projections.

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The Hospice of the Florida Suncoast, Inc. (CON #9964): Based on the financial position of the applicant and support from the foundation, funding for this project and all capital projects should be available as needed. Overall the applicant has a slightly weak but adequate short-term position with an adequate long-term position. This project appears to be financially feasible assuming the applicant meets its projections. Samaritan Care Hospice of Manatee County, Inc. (CON #9972): Assuming the applicant will be added to its parent company’s credit agreement as indicated by the lender, funding for this project should be available as needed. This project appears to be financially feasible assuming the applicant meets its projections. Medicaid/Charity Care: Evercare Hospice of Manatee County, Inc. (CON #9960) accepts all patients without regard to gender, national origin, race, creed, sexual orientation, disability, age, and place of residence or ability to pay. Approximately one percent of services are provided to indigent/charity patients. 34.5 percent of Evercare’s FY 2005 non-Medicare net revenue was Medicaid. Schedule 7A shows $13,045 for charity care in year 1, and $39,036 for charity care in year two. Medicaid patient days are projected at 7.9 percent in year 2. HCR Manor Care Hospice of Florida, Inc. (CON #9961) has no history of Medicaid services. However the company states that it will adhere to the necessary policy as it establishes hospice services in Hospice Service Area 6C. Schedule 7A shows charity care in year 1 $32,200 and $57,100 in year 2. Medicaid patient days are projected at 22 percent in year two. LifePath Hospice & Palliative Care, Inc. (CON #9962) has a history of providing services to all persons regardless of ability to pay including Medicaid patients and the medically indigent. In 2006, more then six percent of all patient days were provided to Medicaid or medically indigent patients. Schedule 7A does not have a stipulation for indigent or charity care in year 1 or year two. Medicaid patient days are projected at six percent in year 2. Odyssey HealthCare of Manatee County, Inc. (CON #9963) is a new entity and has no history of service to Medicaid and Medically indigent patients. However Odyssey proposes to provide services to all patients regardless of gender, national origin, race, creed, sexual orientation,

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disability, age, place of residence or ability to pay. Schedule 7A shows $0.00 for charity care in year 1, and $0.00 for charity care in year two. Medicaid patient days are projected at three percent in year two. The Hospice of the Florida Suncoast, Inc. (CON #9964) has a long history of serving Medicaid patients and the medically indigent. During 2006, five percent of Suncoast’s patient days were Medicaid and five percent were un-reimbursed charity care. Schedule 7A shows $23,902 for charity care in year 1, and $63,036 in year 2. Medicaid patient days are projected at six percent in year 2. Samaritan Care Hospice of Manatee, Inc. (CON #9972) states that its related Florida hospice provider, Hospice of Orange-Osceola, currently provides approximately eight percent of its total patient care to Medicaid patients, and approximately three percent to indigent patients. Schedule 7A shows $23,902 for charity care in year 1, and $63,036 in year 2. Samaritan’s patient day Medicaid percentage is projected at 7.9 percent.

G. RECOMMENDATION

Approve CON #9964 to establish a new hospice program in Service Area 6C, Manatee County. Total project costs are $415,087. CONDITIONS: 15. Commitment of $250,000 annually for the first two years of


16. The commitment of 0.5 FTE the first year of operation for the development efforts of a children’s hospice program in the Manatee County communities.

17. The commitment of 0.5 FTE in the first year of operation for the development efforts for community bereavement programs in the Manatee County communities.

18. The commitment of one FTE to be operationalized the first year for the provision of caregiver services to hospice patients. The provision of caregiver services will be provided up to an amount of $33,750 (an estimated cost of $2.23 per day for a five-year period).

19. 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 special outreach to Hispanic children.

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20. The provision of three FTEs to allow for uninterrupted 24-hour care seven days a week to be dedicated to evening and weekend services whose sole responsibility and oversight is that of evening and weekend care.

21. Provision of an AIDS program that will collaborate with existing AIDS Service Organizations in Manatee County in meeting the needs of hospice patients with HIV.

22. The development in one year of a community resource library. This library will include various lay and professional education pieces related to chronic illness, death, dying and bereavement.

23. Within the first two years hire a full-time physician who will develop physician services including palliative care consults within area hospitals, nursing homes and the community.

24. The implementation of a teen volunteer program within the first two years of operation.

25. The expansion in year 1 of The Hospice of the Florida Suncoast’s current children’s and family retreat programs to the residents of Manatee County.

26. Beginning in year 1, a minimum budget of $1,200 per interdisciplinary team for the provision of special wish funds for hospice patients and families.

27. The development, in year 1, of a minimum of one community advisory committee to be composed of residents reflective of the community whose purpose is to provide input and feedback about the needs of the Manatee County community and whose recommendations will be used in the future program development.

28. In year 1, the formation of a Manatee Council of Hospice Ambassadors to lead fundraising efforts on behalf of The Hospice of the Florida Suncoast in Manatee County.

CON #’s 9960, 9961, 9962, 9963 and 9972.

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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: Karen Rivera Health Services and Facilities Consultant Supervisor Certificate of Need Jeffrey N. Gregg

Chief, Bureau of Health Facility Regulation

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state agency action reportflorida anesthesia consultants, p.a., bradenton, florida. one supporter...

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