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STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Greystone Hospice of District 6B LLC/CON #10206

4042 Park Oaks Boulevard, Suite 300 Tampa, Florida 33610

Authorized Representative: Bruce G. Schroeder (813) 675-2352

VITAS Healthcare Corporation of Florida/CON #10207 6300 LaCalma Drive, Suite 170

Austin, Texas 78752 Authorized Representative: Ronald T. Luke, JD, PhD

(512) 371-8166

2. Service District/Subdistrict

Hospice Service Area 6B (Hardee, Highlands and Polk Counties)

B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposals to establish a hospice program in District 6, Hospice Service Area (HSA) 6B. However, letters of support were submitted, as discussed below.

Letters of Support

Greystone Hospice of 6B LLC (CON application #10206) submitted 11 letters of support, signed and dated during November 19 through

December 16, 2013. One letter was undated. A summary of these letters is included below.

CON Action Numbers: 10206 and 10207

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Randall Rees, Administrator at Grace Healthcare of Lake Wales, a skilled nursing care and rehabilitation facility, states that he would “endorse

Greystone Hospice of Florida LLC and would enter into appropriate agreements for their new hospice program”.

Teresa Montoya, Director of Social Services for Florida Presbyterian Homes, a provider with assisted living and skilled nursing facilities in

Lakeland, also writes that “We would be pleased to work with Greystone Hospice and would enter into appropriate agreements for their new hospice program”.

Warren Santander, Interim CEO of Florida Hospital Heartland Medical

Center in Sebring, endorses the applicant’s intent to provide hospice services in Highlands County, stating that he would “be happy to refer our patients and their families to Greystone Hospice”.

Mitch Kuck, Manager at Chatham Pointe, a senior apartment home

complex in Wauchula, states that he is “not as confident in the hospice provider that is currently operating in our area…I have had the opportunity to talk to a representative (of Greystone) and wish to help

endorse their application for a certificate of need in Hardee County”. David M. Clites, Administrator of Interim Healthcare in Lakeland, a Medicaid and Medicare certified agency providing home care services to

clients in Polk, Hardee and Highlands Counties, states that he would refer patients and families to Greystone Hospice and work together in

order to “increase community education and awareness of the benefits of hospice services…”.

Representatives of three health care and senior care organizations located in District 6, Hospice Service Area 6B, wrote in support of Greystone Hospice:

Terry Bucher, Founder, President Emeritus and Director of Education

of the Florida Professional Association of Care Givers (FPACG), a non-profit organization located in Polk County with statewide membership,

serves as a resource to primary health care workers and provides on going educational services for CNAs

Ingra Gardner, Executive Director of NU-HOPE Elder Care Services,

Inc., the Florida Department of Elder Affairs designated lead Agency of Community and Home-Based Services for Highlands and Hardee

Counties

Hope Davis, Manager of Polk County Elderly Services.


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The following two assisted living facilities located in HSA 6B also submitted letters of support:

Damaris Lynch, Resident Care Coordinator for Lake Morton Plaza

Senior Living (Lakeland), a provider of Independent and Assisted Living care

Lois McCloskey, Administrator of The Meadows of Cypress Gardens, an assisted living facility in Lakeland.

The applicant also included a letter from Amy Tucci, President & CEO of Hospice Foundation of America (HFA), who states that “If Greystone

Hospice’s application for a CON is approved, HFA is prepared to continue its work on behalf of the hospice care philosophy with Greystone Hospice”.

VITAS Healthcare Corporation of Florida LLC (CON application

#10207) submitted 36 unduplicated letters of support, signed and dated during November 15 through December 17, 2013. Five letters were unsigned. A summary of these letters is given below.

State Representative Ben Albritton, Florida House of Representatives,

District 56, states that he is impressed with “the VITAS approach to end-of-life care”.1 He indicates that this hospice service area “needs a company that has a long history of providing high quality services,

understands our demographics, and invests in our community for a brighter future in a more general sense”. Representative Albritton also states that he “firmly believes that our communities will benefit from the

unique end-of-life care offered by VITAS”.

Melony M. Bell, Polk County Commissioner, District 2, cites VITAS’ outreach programs that “provide excellent educational tools” for residents will be available. She also states “VITAS will have a positive

economic impact, providing as many as 45 much-needed jobs in their Polk County office”.

Other elected and/or appointed officials submitting similar statements of support for VITAS’ proposed hospice program include:

Sue Birge, Hardee County Commissioner, District 2

R. Todd Dantzler, Polk County Commissioner, District 4

Nathaniel J. Birdsong, Jr., Commissioner of the City of Winter Haven,

and Executive Director of Florence Villa Community Development Corporation

Deric C. Feacher, City Manager of Winter Haven; and

1 District 56 includes DeSoto, Hardee and part of Polk County.


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Bruce Lyon, Executive Director of the Winter Haven Economic

Development Council. Three health care facilities in HSA 6B submitted letters stating they

intend to enter into contractual arrangements with VITAS if the project is approved.

Brian Hess, MBA, CEO of Highlands Regional Medical Center, a 126-bed acute care hospital in Highlands County, shares his positive previous

experience working with VITAS in Collier County, and states that he “would be willing to enter into a contractual arrangement with them” if approved.

Mike Bradley, Administrator of Valencia Hills Health and Rehabilitation

Center in Lakeland, submitted a letter of support and a follow up letter as well. In these letters he states that “as an operator of a 300-bed SNF in Polk County I am very familiar with the current hospice services

offered in the area. Furthermore, I believe the market would benefit from a hospice program with the experience VITAS has and their innovative

approach to end of life care”. Mr. Bradley adds that he would “be willing to enter into an appropriate contractual arrangement with VITAS in order that they may provide hospice services to patients in need of inpatient

level of care in existing beds in our facility”.

Tom Glass, Administrator at Haines City Health Care, a nursing home in

Polk County, also states intent to form a contractual agreement with VITAS to provide hospice services in their facility.

Marcia Williams, Director of Case Management at Select Specialty Hospital in Orange County, writes that because she practices in a large

acute care facility “I often see patients from Polk County. The resources for hospice in Polk County are currently very limited. The provider in

Polk County has not been able to manage the needs of my advanced patients” and that “over the last four years I have come to realize that VITAS is the only hospice who can successfully manage my complex

patients”.

The applicant also includes a letter to Ronald A. Fried, Executive Vice

President, Development and Public Affairs, VITAS Innovative Hospice Care from Sara Rosenbaum, CREATION Health Community Specialist

with Florida Hospital Heartland Medical Center. Ms. Rosenbaum describes the development of the CREATION program and its goal to “change local culture to one of whole person health and wellness through

education about each of the letter of the word CREATION…each a principle of health”. The program will be targeted to community members and Heartland employees. She indicates that VITAS has


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proposed a grant of $107,000 as part of a partnership proposal with Florida Hospital Heartland.

Warren Santander, Interim CEO of Florida Hospital Heartland Medical

Center of Sebring states that “VITAS’ continuum of care with highly-trained professionals will help our patients and their families throughout their health care journey” and “we would be happy to refer our patients

and their families to VITAS”. He also states Heartland staff “would work with VITAS to increase community education and awareness of the benefits of hospice services for terminally ill patients and their families.

Ann M. Barnhart, CEO Heart of Florida Regional Medical Center in Polk

County states VITAS recognizes the importance of serving “our community’s underserved populations” and “we support its plan for addressing these critical needs”. She also states “we would be proud to

work with VITAS as a partner in serving patients and their families facing life-limited illness”. She also cites VITAS success with community

outreach programs. Other health care providers submitting letters of support for VITAS

include:

Sandra O’Dowd, Executive Director of Savannah Cottage Memory

Care Residences in Lakeland

Ann Claussen of Central Florida Health Care, a provider of health care

centers in Polk, Hardee & Highlands Counties

Brooke Ellis, Executive Director of Serenades Memory Care Assisted

Living in Orange County

Melissa Arnold, Director of Operations, Senior Helpers in Orlando

Charlie Allie, District Director for America in Home Care of Central

Florida

Jodi Woodside, Executive Director, and Ms. Nancy Tickle, Resident

Services Coordinator, at Arden Courts Memory Care Community (not located in the service area)

Dr. Juan Fernandez-Maceiro, Central Florida Primary Physicians in Poinciana

Hank Charpentier, Administrator and CEO of Partners in Healthcare (Seminole and Orlando Counties).

Kim Staczek, Senior Director of Partner Relationships with the American Cancer Society; April Carpenter, Campaign Manager for the Leukemia &

Lymphoma Society, Northern & Central Florida Chapter; and Kim Hanna, President of the ALS Association Florida Chapter, each submitted a letter from their respective organizations in support of VITAS as a

quality hospice provider.


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Additional letters supporting VITAS’ application were submitted from four businesses in and around the service area; two Lakeland based

churches; Polk State College; and three service area residents.

C. PROJECT SUMMARY

Greystone Hospice of District 6B LLC (CON application #10206) seeks authorization to develop and implement a new hospice program in Hospice Service Area 6B, consisting of Polk, Hardee and Highlands

Counties. Greystone Hospice of District 6B LLC is a newly formed development stage corporation authorized to conduct business in

Florida. The applicant’s sister corporation, Greystone Healthcare Management (GHM), provides skilled nursing, assisted living and home health care through licensed facilities in Florida and other states.

Operations management, consulting and customized services will be offered by GHM to the applicant.

The applicant is proposing total project costs of $318,113 with year one operating costs of $1,991,617 and year two costs of $3,779,259.

Schedule C includes the following conditions:

1. Financial Support - Greystone Hospice of District 6B LLC commits to establishment of a new non-profit charitable foundation to

assist in meeting the needs of the residents of Hardee, Highlands and Polk Counties. The new foundation will be funded through $1 million in contributions from Greystone & Co., Inc. during the

initial five-year period of hospice program licensure, with at least $200,000 contributed within 90 days of initial licensure of the proposed hospice program.

The foundation will be designed to distribute funds based on local

needs as demonstrated through a registered not-for-profit organizations’ current or planned work in the community. An example of such programs and organization include, but is not

limited to:

-United Way -Local colleges for nursing scholarships -Programs to raise awareness of hospice services

-Provision of education and training to clinical and volunteer staff who are involved in hospice care -Provision of support or establishment of programs that benefit

hospice patients and/or their families that are not otherwise covered as a reimbursed service


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-Provision of education and training to clinicians within the community

-Reduction of the overall health care cost in the community -Provision of services that might not be otherwise funded or

provided -Other general purposes, with an emphasis on healthcare that benefit Service Area 6B.

The foundation will be prohibited from making contributions that directly benefit Greystone Hospice of District 6B LLC or any

Greystone affiliate. Compliance with this condition will be measured by submission to the Agency of evidence of the legal

organization of the foundation entity, the restrictions on use of foundation funds, and an annual itemization of recipients and amounts of distributed funds, including a description of the

specific programs and services funded to benefit area residents in need.

2. Office Locations - Hospice Service Area 6B includes three counties:

Hardee, Highlands and Polk. Greystone Hospice of District 6B LLC

commits to the development of its initial office in either Lake Wales or Winter Haven in Polk County, and commits to establish a physical presence in Wauchula, Hardee County by the end of year

three of operation, and to maintain that for at least two years thereafter. Compliance will be measured by furnishing the Agency

with copies of relevant portions of signed lease agreements.

3. Fundraising - Greystone Hospice of District 6B LLC commits that it

will not engage in fundraising activities in the service area. Persons wishing to make donations will be encouraged to donate instead to the newly established foundation (described in

Condition #1) or to one of the area’s existing nonprofit hospice foundations. Compliance with this condition will be demonstrated

by submission to the Agency of an annual statement verifying that this has occurred.

4. Reporting - Greystone Hospice of District 6B LLC commits to voluntarily report to the Agency’s “Family Evaluation of Hospice

Care (FEHC) Satisfaction Survey” found at the FloridaHealthFinder.gov website. Compliance with this condition will be measured by submission of the requested information.


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5. Veterans - Greystone Hospice of District 6B LLC commits to partner with the We Honor Veterans program, which recognizes the

unique needs of terminally-ill veterans and their families. Compliance with this condition will be measured by submission of

written acknowledgement from the We Honor Veterans program of the hospice’s involvement.

6. Freestanding Facilities - Greystone Hospice of District 6B LLC affirms that it will not seek to establish or operate freestanding inpatient hospice facilities in Service Area 6B during the first five

years of operation. Compliance with this condition will be measured by Agency records.

VITAS Healthcare Corporation of Florida (CON application #10207), also referenced as VHCF, seeks authorization for the establishment of a

hospice program in Hospice Service Area 6B (Polk, Hardee and Highlands Counties). The proposed hospice program will make available to

residents of this service area the hospice services VHCF has provided in Florida for the past 30 years. The applicant is currently licensed to provide hospice care in 16 Florida counties. If approved, the hospice

program for Subdistrict 6B will be operated under an existing license.2 The program will be certified by Medicare and Medicaid. VHCF operates all hospice programs in Florida under one Medicare provider number,

and this would include the proposed project in 6B. Therefore the applicant states they can begin offering hospice services immediately in

this area after final CON approval. The applicant is proposing total project costs of $893,468 with year one

operating costs of $246,092,247 and year two costs of $255,119,334. Schedule C includes the following conditions:

1. The intent of VHCF is to provide high quality, cost-effective and

coordinated services for its patients/families and the community-at-large. VHCF will make a meaningful contribution to Subdistrict 6B to those persons with non-cancer illnesses in need of hospice

care and hospice patients in need of continuous care. This will be accomplished through its proven experience and programming and

its successful operating model, and assured via the conditions proposed by VHCF.

2 VHCF does not specify which existing license will include the proposed program.


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Please note that we have not listed as conditions services and procedures that are required by state and federal law because we

understand the conditions in a CON application are intended to be actions the applicant commits to voluntarily. In addition to these

conditions, VHCF will comply with all state and federal laws. VHCF commits to the following core service, non-core service and operational/programmatic conditions identified below and commits

to meet all of the requested reporting requirements and time frames as defined in Chapter 59C-1.013 and 59C-1.021, Florida Administrative Code.

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

o The first population subgroup is defined as hospice patients in

need of continuous care: VHCF will provide at least 2.4 percent

of its total patient days as continuous care by year two. This will be measured via a signed declaratory statement by VHCF

which may be supported by review of patient day reports by type and month produced by VHCF.

o The second population subgroup is defined as hospice patients

with diagnosis other than cancer. VHCF will offer specific programs and make targeted outreach efforts to serve patients with non-cancer diagnoses. This will be measured via a signed

declaratory statement by VHCF which may be supported by review of admission reports by patient diagnosis produced by

VHCF.

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

provision it will meet or exceed the following quality and patient satisfaction indicators:

o Pain Control: On the first day of hospice care responsive patients will be asked to rate their pain on the 0-10 World

Health Organization pain scale (severe pain to worst pain imaginable). A pain history will be created for each patient. These measures will be recorded in VHCF’s proprietary

information management system, VITAS Exchange (or “Vx”) via a telephone call using the telephone keypad for data entry.

Seventy percent or more of patients who report severe pain (seven-10) will report a reduction to five or less within 48 hours after admission. Florida Statutes 400.60501 requires only a 50

percent reduction in 96 hours, so this commitment exceeds Florida statutory requirements and is a significant commitment to quality care.


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o Death Attendance: A VHCF staff member or volunteer will attend at least 90 percent of all deaths to ensure patients do not

die alone. This will be measured via a signed declaratory statement by VHCF which may be supported via review of

patient medical records. o Patient Family Satisfaction: VHCF will achieve an overall

patient satisfaction score of 90 percent or above on the patient’s

family evaluation of care while under the care of VITAS. This is determined by a mail-in survey sent by VHCF to the patient’s family and measured by averaging all scores.

o Discipline Specific Satisfaction: VHCF will achieve an overall Registered Nurse satisfaction score of 90 percent or above on

patient’s family satisfaction with the VHCF nurse while under the care of VITAS. This is determined by a mail-in survey sent by VHCF to the patient’s family and measured by averaging all

scores. o Pet Therapy: Implement a pet therapy program to begin

immediately. PetPals is a program where screened dogs visit shut-ins, nursing homes, assisted living facilities, adult day care center and Alzheimer patients. This program offers a visit

with a pet to those in the community who may respond to the love and comfort of a pet therapy dog. VHCF has an affiliation with the Central Florida Toy Dog Club which has sister

organizations throughout the state. Volunteers and their pets are trained to assist patients and their families in any setting.

4. Other Conditions: VHCF has conditioned the application on the

provision it will meet or exceed the following operational and

programmatic indicators: o Establish satellite hospice offices in Hardee County and

Highlands County during the first year of operation. Establish a second hospice office in Polk County during the second year

of operation. o Create a Mobile Hospice Education Unit in the first year of

operation. The Mobile Hospice Education Unit will travel to

various community centers, health care facilities and shopping centers in the area to provide hospice outreach and education.

The Mobile Hospice Education Unit staff will provide pamphlets, brochures and firsthand information about hospice services.

o Implement a TeleCare Program consisting of 24/7 nurse

availability to begin immediately.


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o Establish a Local Ethics Committee to begin upon certification, as discussed in Schedule B Section E2 of this application.

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

CarePlanIT is discussed in Schedule B Section E2. o VHCF will work with Palliative Medical Associates of Florida to

implement its palliative care program in Subdistrict 6B within

one year of licensure. This program is discussed in Schedule B, Section E3(d). As indicated in the letter included from Mary Zalaznick, Senior Vice President and Administrator of Palliative

Medical Associates of Florida, in TAB 11, this will not require any monetary commitment from VHCF.

o Provide palliative radiation, chemotherapy and transfusions as appropriate for treating symptoms.

o Commit to having every patient being assessed by a physician

within 24 hours of admission to the hospice. Medical directors provide patient visits in their residence.

o Medical directors must be board-certified in hospice or palliative care medicine, or apply for board-certification within five years of employment.

o RNs are encouraged to become certified in hospice and palliative care nursing. By the second year of operation, 50 percent of all supervisory nurses will attain such certification.

o Masters of Divinity or equivalent graduate degree from an accredited seminary or theological school required for

chaplains. o Social workers are Master’s level or licensed clinical social

workers.

o Although bereavement services are generally provided to the family for one year after the death of the patient, services will be available beyond one year, if needed.

o VHCF agrees that it will not engage in any fundraising events or campaigns to obtain charitable contributions from residents of

the subdistrict. VHCF will respond to inquiries from persons seeking to make charitable contributions for hospice services with information on relevant 501(c)(3) organizations that benefit

Florida residents. o Establish a clinical Pastoral Education program to begin

immediately. The program description is found in TAB 10. o VITAS, as the parent company of VHCF, commits to spend

$50,000 for five years, or a total of $250,000 through

institutions of higher education, disease advocacy groups and professional associations located in Subdistrict 6B to provide educational content on end-of-life care for degree programs,

continuing professional education and community education.


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These funds may be used to develop curriculum, provide scholarships, underwrite seminars and conferences, and fund

faculty or research positions. This condition will be measured by a signed declaration by VHCF and documentation of the

expenditure and use of funds.

Hospice programs are required by federal and state law to provide services to everyone requesting them and therefore the Agency would not place conditions on a program to provide legally required services such as palliative radiation and chemotherapy and care to the indigent and charity patients. The applicants’ proposed conditions are as they stated. However, many of these conditions are required hospice services and as such would not require condition compliance reports. Should a project be approved, the applicant’s proposed conditions would be reported in the annual condition compliance report as required by Rule 59C-1.013 (3) Florida Administrative Code. Section 408.606 (5) Florida Statutes states that “The agency may deny a license to an applicant that fails to meet any condition for the provision of hospice care or services imposed by the agency on a certificate of need by final agency action, unless the applicant can demonstrate that good cause exists for the applicant’s failure to meet such condition”.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review criteria found in Section 408.035, Florida Statutes, rules of the State of

Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code. These criteria form the basis for the goals of the review process. The goals represent desirable outcomes to be attained by successful

applicants who demonstrate an overall compliance with the criteria. Analysis of an applicant's capability to undertake the proposed project

successfully is conducted by evaluating the responses provided in the application, and independent information gathered by the reviewer.

Applications are analyzed to identify various strengths and weaknesses in each proposal. If more than one application is submitted for the same

type of project in the same district (subdistrict or service planning area), applications are comparatively reviewed to determine which applicant best meets the review criteria.

Section 59C-1.010(3)(b), Florida Administrative Code, prohibits any amendments once an application has been deemed complete. The

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


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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, Jessica Hand, analyzed the application in its entirety with consultation from financial analyst, Felton Bradley, with the Bureau of Central Services, 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 39, Number 189 of the Florida Administrative Register dated September 27, 2013, a hospice program net need of one was published

for Service Area 6B for the January 2015 Planning Horizon. Service Area 6B is currently served by three hospice providers: Compassionate Care Hospice, Cornerstone Hospice & Palliative Care Inc., and Good Shepherd

Hospice. A fourth provider, Hope Hospice and Community Services, Inc. was de-licensed September 7, 2012.

Therefore, the two co-batched applicants are applying in response to published need.

Hospice admissions in District 6B for the 12-month period ending June 30, 2013 are listed by provider in the following chart:

Hospice Admissions in District 6B

for the 12-Month Period ending June 30, 2013 Compassionate Care Hospice 413

Cornerstone Hospice & Palliative Care Inc. 892

Good Shepherd Hospice 3,491

Hope Hospice And Community Services, Inc.* 35

Total 4,831 Source: Agency for Healthcare Administration’s Florida Need Projections for Hospice Programs for the January 2015 Hospice Planning Horizon, published September 27, 2013.

*Delicensed 9/7/12.


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Greystone Hospice of District 6B LLC (CON application #10206) undertook its own needs assessment related to specific conditions in

Service Area 6B, including extensive research into hospice utilization by patient race/ethnicity, age and diagnosis, as well as county and age

specific mortality rates and trends. The applicant concludes that while there are no populations whose needs are being completely unmet, there are ongoing needs that will increase over time however, as the population

of the service area increases and ages and as the composition of that population changes. Specifically, the applicant states there is an ongoing need for a hospice program committed to meeting the cultural, language

and religious needs of the large and growing Hispanic community.

Greystone commits to the service of indigent and low-income populations regardless of race, ethnicity, religion or ability to pay. The applicant notes that incomes in HSA 6B fall below the statewide average (see chart

below), particularly in Hardee County, making their commitment to low income persons particularly relevant to this project.

Estimated Income All Ages Service Area 6B, 2011

County

Income Percent in Poverty Per Capita Median Household

Hardee $24,898 $38,046 31.8%

Highlands $29,809 $34,913 18.8%

Polk $33,447 $44,398 19.2%

Florida $39,636 $47,827 17.0% Source: CON application #10206, page 15.

In summary, Greystone Hospice of District 6B LLC states it will enhance access to hospice care within this service area based on the following

demographic trends:

Between 2010 and 2015, the rate of Hispanic population growth in

the area is more than double the rate of overall population growth. In Service Area 6B the Hispanic population is forecast to increase

another 13.5 percent as compared to 12 percent in the state during the same time period.

By 2015, Hispanics are expected to comprise 43 percent of the Hardee

County population and 20 percent of the Service Area’s total population of 766,530.

None of the counties comprising HSA 6B ranked above the overall

Florida per capita income or median household income. In addition, a higher percentage of the residents of the three counties fell below the poverty level than did Floridians on average (17 percent).

Based on measures of per capita income, median household income and percent of population below poverty level, Hardee County ranks

as the poorest county in the service area.


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As noted in conditions predicated upon award, the applicant will establish two office locations in HSA 6B, as well as other conditions

designed to enhance quality of care to service area residents. Greystone will market their services to the broad spectrum of patient needs in this

area and will not “cherry pick” hospice patients based on diagnosis, ability to pay, or any other market factor.

VITAS Healthcare Corporation of Florida (CON application #10207) has undertaken its own needs assessment for HSA 6B in order to identify the populations with greatest need.

The applicant notes that populations for this area are growing, with most

residents located in Polk County. HSA 6B is served by three hospice providers (Good Shepherd, Compassionate Care and Cornerstone Hospice), and a fourth provider (Hope Hospice) was recently absorbed by

Good Shepherd, reducing the number of providers and thus patient choice, despite hospice utilization slowly trending upwards in this area.

VHCF did not identify major racial or ethnic groups underserved markedly in this district; however, the applicant identifies four areas of

need that comprise the focus of the application:

Increase the hospice use rate for elderly residents with Non-Cancer

diagnosis; particularly those with cardiac disease: Non-cancer patients over age 65 comprise 75 percent of net need for hospice

services in this area; the applicant analyzed causes of death for HSA 6B to conclude heart disease is the leading cause of death for the past

three years in this service area. The applicant notes its experience providing care to these patients: In 2012, 69.75 percent of VHCF’s Florida patients had a non-cancer diagnosis, compared to 65.71

percent for existing 6B hospice providers and 66.03 percent for Florida overall.

Reduce the percentage of hospice patients dying in hospitals by providing continuous care to more patients when appropriate: The

applicant provides two charts which demonstrate their performance in this area; compared to other 6B providers and the state (see Charts 1 and 2 below). The applicant conditions to provide at least 2.4 percent

of patient days as continuous care.

Increase access to hospice services for residents of Hardee County:

The applicant analyzed data to conclude that Hardee County has the lowest hospice penetration rate in 6B; in order to improve access and hospice service, VHCF will open three offices (one per county) located

strategically in each county to maximize access to populations with the greatest need. The applicant will also operate a Mobile Hospice

Education Unit (see conditions).


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Reduce the deficiency rate for hospice services: VITAS indicates this

is based on the ratio of survey deficiency citations per 1,000 hospice admissions. The applicant submits Chart 3 below to show that existing 6B providers have a lower quality of care than VHCF.

Chart One

Source: CON application #10207, page 15.

Chart Two

Hospice Patient Days and Continuous Care Days, 2011

Hospice Name

Continuous

Home Care

Total Hospice

Days

Percent

Continuous Care

Cornerstone Hospice 7,970 257,877 3.1%

Good Shepherd Hospice 2,987 243,000 1.2%

Compassionate Care Hospice of Miami Dade, Inc.

239

20,631

1.2%

Hope Hospice 727 498,031 0.1%

6B Providers (Statewide) 63,917 5,923,121 1.1%

VHCF 120,558 1,962,943 6.1%

All Florida Hospices 203,709 8,454,195 2.4% Source: CON application #10207, page 16.

5.6 4.9

4.2 3.7

2.4 1.9

0

1

2

3

4

5

6

3 Year Average Percentage of Medicare Beneficiary Hospice Patients that Died in a Hospital, 2009-2011


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Chart Three

Deficiencies Per 1,000 Hospice Admissions, Calendar Years 2010-2012 2010 2011 2012 Overall 2010-2012

Compassionate Care N/A 16.53 0 4.74

Cornerstone Hospice 1.24 0 2.48 1.26

Good Shepherd 0 0.93 0 0.30

Hope Hospice 1.49 5.18 15.09 5.27

6B Providers (Statewide) 0.43 1.70 1.25 1.13

VHCF 0.05 0 0.24 0.10 Source: CON application #10207, page 19.

The reviewer notes that during 2012 Compassionate Care reported 301 admissions compared to VHCF’s total admissions of 20,576 for its three

programs. Due to the varying annual volumes, the validity of these comparisons in Chart Three is uncertain.

VHCF discusses the qualifications and experience of its parent organization, VITAS Healthcare Corporation:

One of the largest hospice providers in the United States, with 11,500

professional employees

37 hospice inpatient units, as well as programs providing home care,

totaling 51 hospice programs in 18 states and D.C.

VITAS is a wholly owned subsidiary of Chemed Corporation

VHCF was the first hospice incorporated into Dade County, Florida in 1978.

Additional quality of care and service features will be discussed in detail in the Quality of Care segment of this report. The applicant includes a

detailed history of VITAS’ company and analysis of need with the application in Supporting Documents (Volume II and III).

Comparative Review

VHCF addresses the co-batched applicant, Greystone Hospice of Subdistrict 6B, and provides reasons why they believe VHCF is the

superior applicant, summarized below:

Greystone is a nursing home company with no known hospice

operations past or present.

Greystone has grown primarily through acquisition of existing

companies and not through starting its own programs in new markets. It has not shown the corporate ability to establish a new

program in a market with strong competitors.

Greystone has not been able to demonstrate a history of delivering

consistently high quality care to Florida residents through its existing nursing homes.


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Greystone has filed an application for a hospice program in every

subdistrict with published need during this batching cycle. As such, it has shown more interest in entering the hospice market anywhere than in meeting the particular needs of Subdistrict 6B residents.

Greystone has the option of starting hospice operations in the other states where it has existing nursing home operations, Indiana and

Ohio. Neither of these states regulates hospice services through a CON program.

VITAS Experience in the Florida Marketplace

The applicant submits the following chart demonstrating VITAS’ experience providing hospice services to the Florida market place in order to demonstrate its ability to begin a program in HSA 6B quickly and

efficiently:

Projected vs. Actual Admissions in First Two Years of Operations

Hospice

Subdistrict Projected Actual Difference

Year One Year Two Q1-Q4 Q5-Q8 Year One Year Two

VHCF 4A 162 297 329 449 167 152

VHCF 8B 186 354 183 406 (3) 52 Source: CON application #10207, page 30.

The reviewer confirms the projected admissions for Service Areas (SA)

4A and 8B shown above and the actual admissions for VHCF in SA 4A are correct. VHCF 8B slightly exceeded the actual year one (with 197) and two (423) admissions shown in the above table.3

VITAS also provided a chart entitled “Time between CON Issuance and

Licensure for Recently Approved CONs”, which demonstrated that it does bring its programs into operation very quickly after receiving final approval in a new service area. The time between CON issuance and

licensure for these two approved CONs in HSA 4A and 8B was 22 and 46 days respectively, compared to a range of seven to 17 months for hospice companies based in other states. This was confirmed by the CON

reviewer with the days cited based on the date of the final orders in these cases.

VHCF notes that its presence in the above two markets did not adversely impact existing providers. The CON reviewer notes that there is

published need for an additional program in Hospice Service Area 6B; therefore, the impact on existing providers is of minimal concern.

3 Source: State Agency Action Reports for CON applications #10065 and #9969 year one and two

projections. Hospice utilization from ‘Florida Need Projections for Hospice Programs’ published 9/27/13, 9/28/12 for VITAS’ SA 4A utilization and 10/1/10 and 10/2/09 for SA 8B utilization.


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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.

Each co-batched applicant is responding to published need for an additional hospice program for the January 2015 planning

horizon.

Each applicant discusses serving populations they believe to be

underserved.

Greystone Hospice of District 6B LLC (CON application #10206) states that based on its own extensive research, no populations within HSA 6B have completely unmet needs;

however, ongoing needs exist which will increase as population expands. The applicant identifies the Hispanic community, low income residents and an increased presence in Hardee County as

specific areas of need.

VITAS Healthcare Corporation of Florida (CON application #10207) states that based on its own research, non-cancer patients (particularly those with cardiovascular disease), patients

in need of continuous care to avoid hospital admission, and residents of Hardee County are identified as underserved groups in HSA 6B.

(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.

Greystone Hospice of District 6B LLC (CON application #10206) expects to provide approximately 2.5 percent of its total patient days to inpatients during the first two years of the

proposed project’s operations, requiring 582 general inpatient days of care in year two, the equivalent of 1.6 inpatient beds. The applicant expects to deliver inpatient care through contractual

arrangements with existing health care facilities. The applicant attests to the experience of its sister organization GHM’s history of


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making such contractual arrangements (as an operator of assisted living facilities and nursing homes), and includes a copy of the

applicant’s “Policy #A-23.0 Inpatient Care” and Inpatient Agreement documents that will govern its approach to inpatient

care (Tab 4, CON application #10206). The applicant notes two providers, Grace Healthcare of Lake Wales and Florida Presbyterian Homes, submitted letters indicating willingness to

work with Greystone Hospice on this issue. VITAS Healthcare Corporation of Florida (CON application

#10207) states its intent to provide inpatient care through contractual agreements with area hospitals and nursing homes.

The applicant includes letters of commitment to contract for inpatient beds with Valencia Hills Health and Rehab, Haines City Healthcare and Highlands Regional Medical Center, and a letter of

interest to work with VITAS to meet the needs of area residents from Heart of Florida Regional Medical Center, in the “Supporting

Letters” portion of the application.

(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.

Each of the co-batched applicants commit to the care of those patients who do not have a primary caregiver at home, who are

homeless and patients diagnosed with AIDS. Both applicants outline a plan of care and/or program designed to provide for the needs of patients in each of the previous circumstances, and

provide supporting documentation to this effect.

(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 6B consists of Hardee, Highlands and Polk

Counties. Both applicants commit to the establishment of an office located in Polk County. VHCF further commits to the

establishment of offices in Hardee and Highlands Counties, with all three VHCF offices opened within the first year of operations.

Greystone Hospice commits to establishing a physical presence (satellite office) in Hardee County by the end of the third year of operations.


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VHCF is the only applicant committing to an office location in Highlands County.

(5) Preference shall be given to an applicant who proposes to

provide services that are not specifically covered by private insurance, Medicaid, or Medicare.

Each of the co-batched applicants states its intent to provide a broad range of non-core services which are not specifically covered by private insurance, Medicaid or Medicare, and provide details

and supporting documentation of such programs in their respective applications.

Both applicants further condition their application on the provision of non-core services; however, Greystone Hospice does not specify

any details of services provided by the condition, while VHCF conditions to a fully explicated list of services.

b. Chapter 59C-1.0355, Florida Administrative Code contains the

following general provisions and review criteria to be considered in

reviewing hospice programs. (1) Required Program Description (Rule 59C-1.0355(6), Florida

Administrative Code): An applicant for a new hospice program shall provide a detailed program description in its certificate

of need application, including:

(a) Proposed staffing, including use of volunteers.

Greystone Hospice of District 6B LLC (CON application #10206): As reflected in Schedule 6A of the application, the

following is the proposed staffing for each of the first two years (CYs 2015 & 2016) of operation.


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Position Year One FTEs Year Two FTEs Administrator 1.00 0.0

Director of Clinical Services 1.00 0.50

Spiritual Counselor 1.00 0.50

Medical Social Worker 1.10 1.10

Office Manager (Clerical Staff) 1.10 0.90

Billing Clerk 0.50 0.50

Bereavement Counselor 0.50 0.30

Medical Director-Contract 0.15 0.10

Alternate Medical Director-Contract 0.10 0.05

Continuous Care (RNs & HHAs) 2.01 1.99

Hospice Liaison (Marketing)/Patient Care Navigator

1.50

1.00

RNs 3.30 3.20

Hospice Aides/Homemakers 4.10 4.00

Coordinator of Volunteers 0.50 0.58

Dietary Counselor 0.01 0.01

Total FTEs 17.87 14.73 Source: CON application #10206, Schedule 6A.

It is noted that year one FTEs for the proposed project

exceed year two FTEs. It appears that the applicant incorrectly completed year two’s Schedule 6A placing the

“New Total Number of FTE Staff” year two end totals in the “FTE Staff Added By The Project” column. The 14.73 FTEs shown above are added to year one total to get the

appropriate total FTE staff numbers for year two of 32.60.

Greystone Hospice states the staffing ratios are based on the experience of Greystone Hospice’s affiliate organizations in Florida, and the experience of individuals employed by

Greystone Hospice with expertise in hospice management. The applicant notes Schedule 6 does not include volunteers, which it states “will be vigorously recruited”. Greystone

includes a copy of the job description for the Director of Volunteers position listed in Schedule 6 as well as various

types of volunteer positions (in the application’s Tab 7). VITAS Healthcare Corporation of Florida (CON

application #10207): Schedule 6A shows the following proposed staffing for years one and two of the proposed

project (ending March 31, 2015 and 2016):


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Position Year One FTEs Year Two FTEs General Manager 1.00 1.00

Admissions/Hospice Res/Comm. Liaison

3.99

5.33

Admissions Nurse 1.00 1.00

Bereavement Manager 1.00 1.00

Business Manager 0.88 1.00

PC Secretary 1.08 1.63

Receptionist/Courier 1.58 3.00

Medical Director/Physician 0.66 1.27

Team Director (RN) 1.08 2.33

Continuous Care Manager -- 0.92

RNs 3.23 7.70

LPN/Aides 8.09 27.71

On-Call Representatives 1.58 2.00

Respiratory Therapist 0.17 0.30

Social Worker 1.21 1.96

Chaplain 1.00 1.46

Total 27.54 59.61 Source: CON application #10207, Schedule 6A and page 74.

The applicant notes that volunteer hours are expected to equal or exceed five percent of paid employee hours.

(b) Expected sources of patient referrals.

Each of the co-batched applicants included letters of support from agencies and persons likely to make referrals to hospice services.

Greystone Hospice of District 6B LLC (CON application

#10206) includes the following chart detailing expected sources of referrals:

Source % Of Referrals

Hospitals 36

Physicians 23

Skilled Nursing Facilities 12

Patient, Family or Friend 9

ALF 5

Home Health Agencies 1

Churches, Service Orgs., Other 14 Source: CON application #10206, page 36.

VITAS Healthcare Corporation of Florida (CON application #10207) states that referrals will come from area physicians, hospitals, clergy, social service agencies,

disease advocacy groups, nursing homes and other health care providers, family members and patients themselves.


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(c) Projected number of admissions, by payer type, including Medicare, Medicaid, private insurance, self-

pay, and indigent care patients for the first two years of operation.

Greystone Hospice of District 6B LLC (CON application #10206) provides the following table illustrating its projected

number of admissions by payer type for the first two years of operations.

Projected Number of Admissions by Payer Type

For Greystone Hospice of District 6B LLC

Service Area 6B Payer Type Year One Admits Year Two Admits

Medicare 212 330

Medicaid 9 14

Private Insurance 4 5

Indigent/Charity 15 23

Total 240 372 Source: CON application #10206, page 36.

VITAS Healthcare Corporation of Florida (CON

application #10207) submits the following chart showing projected admissions and patient days for years one and two

of the project:

VITAS Healthcare Corporation of Florida Admissions and Patient Days

First Two Years by Payer Payer

Year One Admissions

Year Two Admissions

Medicare 234 443

Medicaid 11 22

Indigent 4 7

Private Insurance/Self-pay/Other 5 10

TOTAL 255 482 Source: CON application #10207, page 77.

(d) Projected number of admissions, by type of terminal

illness, for the first two years of operation.

The co-batched applicants provide the following tables

illustrating the projected number of admissions by type of terminal illness for the first two years of operation.


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Greystone Hospice of District 6B LLC (CON application #10206):

Projected Number of Admissions by Diagnosis

For Greystone Hospice

Service Area 6B Disease Year One Year Two

Cancer 79 123

Non-cancer 161 249 Source: CON application #10206, page 36.

The applicant projects to serve 240 patients in year one and 372 patients in year two.


application #10207):

Projected Number of Admissions by Diagnosis For VHCF Service Area 6B

Terminal Illness Year One Year Two

Cancer 76 144

HIV/AIDS 3 5

Respiratory 21 40

Cardiac 33 62

Alzheimer’s/Cerebral Degeneration

53

100

Cerebrovascular/Stroke 15 28

Other 54 103

Total 255 482 Source: CON application #10207, page 78.

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

operation. The co-batched applicants provide the following tables for

the projected number of admissions by age cohort.


Projected Admissions by Age Group for

Greystone Hospice Service Area 6B

Admission Type Year One Year Two

Under 65 36 56

65+ 204 316

Total 240 372



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VITAS Healthcare Corporation of Florida (CON application #10207):

Projected Admissions by Age Group for

VHCF

Service Area 6B

Admission Type Year One Year Two

Under 65 32 60

65+ 223 422

Total 255 482


(f) Identification of the services that will be provided

directly by hospice staff and volunteers and those that

will be provided through contractual arrangements.

Greystone Hospice of District 6B LLC (CON application #10206) states it will provide the core services directly by hospice staff and volunteers (nursing, social work, pastoral

or counseling services, bereavement, home health aides, homemaker and chore services). Additional services available through contractual arrangement include: medical

director, alternate medical director, physical/occupational/ speech therapy, dietary/nutritional counseling, pharmacy,

supplies/durable medical equipment, patient transport and infusion therapy.

VITAS Healthcare Corporation of Florida (CON application #10207) will provide core services by VHCF staff

and volunteers (physician services, nursing services, social work services, pastoral and dietary counseling). Additional services will be contracted as needed by patients.

(g) Proposed arrangements for providing inpatient care.

Each of the co-batched applicants states intent to provide inpatient level of care through contractual arrangements

with existing area health care facilities. Greystone Hospice of District 6B LLC (CON application

#10206) provides a letter of support from one nursing home willing to enter into contractual arrangements for inpatient

care. Greystone Hospice anticipates 2.5 percent of total annual patient days for inpatient care during the first two years of operations.


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VITAS Healthcare Corporation of Florida (CON application #10207) provides three letters of support from

facilities willing to enter into contractual arrangements for inpatient level of care (one hospital and two nursing homes).

(h) Proposed number of inpatient beds that will be located in

a freestanding inpatient facility, in hospitals, and in

nursing homes.

The applicants indicate that they will contract with hospitals

and nursing homes but do not provide specific numbers of inpatient beds their programs will utilize in these facilities.

(i) Circumstances under which a patient would be admitted

to an inpatient bed.

Greystone Hospice of District 6B LLC (CON application

#10206) references its policy regarding admissions of patients to inpatient beds, Policy #A.23.0 Inpatient Care, which complies with Federal Medicare Guidelines for hospice

inpatient care. The applicant states in addition to general admission criteria, inpatient admissions will only occur during circumstances when a patient’s acute care needs

cannot be adequately managed or controlled in the home setting, including:

Pain Control

Symptom Control

Imminent death with symptoms necessitating frequent

physician and nursing intervention

Medical-surgical procedures or therapies aimed at

palliation of symptoms

Acute psychological problems such as extreme fear or

anxiety not manageable at home

Provision of a safe and supportive environment to the

terminally ill individual during periods of acute psychosocial and/or spiritual breakdown of the primary

caregiver(s); and

Primary caregiver incapable of continuing daily care in

the home setting.


application #10207) states that inpatient episodes are for respite care or stays of short duration (up to five days), and

intended to provide a break for caregivers/family or to control pain/symptoms that cannot be managed at home.


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The applicant includes samples of inpatient agreements between VHCF and various provider types in the

application’s Tab 17.

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

As stated previously, each of the co-batched applicants intends to provide care to persons who do not have a primary caregiver in the home.

(k) Arrangements for the provision of bereavement services.

The co-batched applicants each state intent to provide substantially similar bereavement programs and services

extending over 12 months when needed, and provide summaries and supporting documentation of these services

within the applications. However, the reviewer notes that VHCF is the only applicant to specify provision of bereavement services beyond the time period required by

federal regulations as a condition predicated upon award.

(l) Proposed community education activities concerning

hospice programs.

Each of the co-batched applicants provides substantially similar descriptions of community education programs and services. The reviewer notes that both applicants condition

their application to the provision of funds for purposes that include community education.

(m) Fundraising activities.

Each of the co-batched applicants conditioned their application to a commitment not to engage in direct fundraising activities (see conditions).


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3. Statutory Review Criteria

a. Is need for the project evidenced by the availability, quality of care, accessibility and extent of utilization of existing health care

facilities and health services in the applicant’s service area? ss. 408.035(1)(a) and (b), Florida Statutes.

Need for an additional hospice program is evidenced by the availability, accessibility and extent to utilization of existing services in this service area. The co-batched applicants are responding to published need of one

hospice program in Hospice Service Area 6B.

The following chart illustrates hospice admissions for the past five years. As shown below, admissions have overall increased from 4,423 in the year ending June 30, 2009 to 4,831 in the year ending June 30, 2013.

Hospice Admissions for Service Area 6B

Five-Year Period Ending June 30, 2013 12 Months Ending June 30 Admissions

2013 2012 2011 2010 2009

4,831 4,607 4,787 4,580 4,423

Source: Agency for Health Care Administration Florida Need Projections for Hospice Programs, 2009-2013.

Greystone Hospice of District 6B LLC (CON application #10206) undertook its own needs assessment in order to conclude there are no populations within Service Area 6B whose needs are completely unmet;

however, the applicant anticipates population growth and increasing cultural diversity will necessitate hospice services sensitive to the specific populations in HSA 6B, such as the growing Hispanic community, as

well as low income residents.

As previously stated, Greystone Hospice is committed to establish a physical presence in Hardee and Polk Counties (with both offices operational by the third year of the proposed program), and has

conditioned the application to this effect.

VITAS Healthcare Corporation of Florida (CON application #10207) quality of care is described in detail in Item E.3.b. below.

VHCF conditions approval of their application upon the establishment of a physical presence in all three HSA 6B counties (Hardee, Highlands and Polk) within the first year of operations.


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VHCF previously identified non-cancer patients (particularly those with cardiovascular disease), patients in need of continuous care to avoid

hospital admission, and residents of Hardee County as underserved groups in HSA 6B. The applicant provides a list of additional cultural

and religious groups for which they have specific hospice programming available, with programs for Jewish patients and Veterans given prominent attention and detail.

VHCF discusses its provision of care compared to the existing service area providers (see Item E.1.a.). Additionally, the applicant cites the

success of VITAS as a provider of efficient service, noting:

VITAS implemented 27 hospice programs nationwide in the past 10 years, including five in Florida.

VHCF is the highest volume hospice in Florida, licensed to serve 16 counties.

VHCF provides a description of training programs for staff that focus on the provision of efficient and effective hospice services and quality of

care.

b. Does the applicant have a history of providing quality of care? Has the applicant demonstrated the ability to provide quality care? ss. 408.035(1), (c), Florida Statutes.

Greystone Hospice of District 6B LLC (CON application #10206) is a newly-formed development stage corporation and as such does not have

a licensure history or accreditations. However, the applicant refers to sister company Greystone Healthcare Management (HCM), a provider of

skilled nursing, assisted living and home health care through licensed facilities in Florida and other states since 2001. The applicant discusses Greystone HCM’s quality of care model applicable to the proposed

hospice program, including:

Greystone Healthcare Managements Provision of Care-operations management, consulting and customized services will be offered by

Greystone HCM to the applicant. Based in Tampa, Greystone HCM manages 18 skilled nursing facilities and one assisted living facility in Florida.

o The applicant lists key principles of Greystone HCM management and notes a customer service model is utilized which solicits feedback from all customers, the results of which are put into

facility quality assurance plans and/or business development initiatives, and also used to recognize and acknowledge deserving

employees and staff members. Greystone HCM clinical operations and community relations are also detailed.


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o Greystone HCM Five Stages of Quality Assurance/Performance Improvement (QAPI): The applicant discusses the five stages

related to this quality control process, detailing each of the following steps: design and scope, governance and leadership,

feedback/data/systems and monitoring, performance improvement Projects (PIPS) and Systematic Analysis/Systemic Action.

o The Greystone Health Network

o Greystone Home Healthcare

Applicant’s Ability to Provide Quality Care - Greystone Hospice

reviews six of the key executive staff personnel who will participate in this capacity with the applicant, and has developed its own Policies

and Procedures Operating Manual for hospice, and detailed job descriptions for hospice staff and volunteers (Volume 2, Tab 6).

Quality Assessment and Performance Improvement Program (QAPI)-

the applicant evaluates all levels of care, including routine home care, inpatient, and continuous home care and respite services in order to demonstrate the proposed program functions according to the mission

and goals of the organization. The applicant’s Quality Assessment Committee is overseen by an Administrator, assisted by a committee

that meets at least four times annually.

Greystone projects 17.87 FTEs in year one and 14.73 additional FTEs

in year two of the proposed project.

The applicant states it will develop and implement a comprehensive emergency management plan for Hardee, Highlands and Polk

Counties upon approval of the proposed project.

Greystone Hospice states it will collect data and information for both

internal analysis and regulatory reporting, and will comply with all

Agency and other government oversight requirements. The applicant has conditioned approval of the project on the voluntary reporting to the Agency “Family Evaluation of Hospice Care (FEHC) Satisfaction

Survey” found at FloridaHealthFinder.gov, to be measured by submission of the requested information.

Agency licensure records indicate during the three-year period ending on December 6, 2013, the 18 Greystone Healthcare Management

Corporation affiliated skilling nursing homes in Florida (2,106 beds) had 64 substantiated complaints. A single complaint can encompass multiple complaint categories. The table below has these listed by

complaint categories.


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Greystone Healthcare Management Corporation Affiliated Nursing Homes

Substantiated Complaint Categories for the 36 Months Ending

December 6, 2013 Complaint Category Number Substantiated

Quality of Care/Treatment 37

Resident/Patient/Client Assessment 9

Administration/Personnel 8

Admission, Transfer & Discharge Rights 6

Physical Environment 6

Resident/Patient/Client Rights 5

Dietary Services 4

Nursing Services 4

Infection Control 3

Falsification of Records/Reports 2

Physician Services 2

Resident/Patient/Client Abuse 1

Unqualified Personnel 1 Source: Agency for Health Care Administration complaint records.

VITAS Healthcare Corporation of Florida (CON application #10207) notes the following evidence of their ability to provide quality of care:

Accreditation by the National Institute for Jewish Hospice (NIJH) for three of its Florida hospices

Joint Commission accreditation of all their hospice programs and the

VITAS corporate body

The first hospice program in Miami-Dade County (1978)

Combined 100 years of senior management experience

VHCF provides hospice care in 16 Florida counties, which accounts

for half the state population.

2012 Average Daily Census (ADC) of over 5,363 patients

VHCF has in excess of 1,600 nurses and provides training and incentives for higher certifications.

VHCF interdisciplinary teams make more than 5.7 visits per patient/week, exceeding the industry average, and include physicians

who make regular patient visits and provide bedside care.

VHCF states that of patients who self-report severe pain between

seven and 10 upon admission, more than 70 percent report a significant reduction of pain and score at or beneath five within the

first 48 hours of service.

VHCF provides 24-hour direct telephone access to the clinical staff as

part of their “TeleCare” Program.

VHCF social workers and chaplains make weekend visits to patients

in long term care (LTC) and assisted living facilities (ALF) (Tab 20 and 33 provide additional protocol for inpatient services).

Bereavement specialists provide grief and loss counseling, memorial

services and other support services for family and loved ones.


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During the 12-month period ending October 31, 2013 VHCF had 961

active volunteers in Florida, trained by VITAS, and 6,800 volunteers nationwide.

Continuous care services manage acute symptoms in the home, LTC

facility or ALF. An average of 6.6 patients received continuous care each day in 2012.

There are 45 active teams in Florida, some primarily LTC and ALF and others a mix of home care/LTC/ALF care; the 2012 ADC for all teams

was 5,363 patients.

VHC has experience in addressing the needs of non-English speaking

communities, and provides literature in multiple languages.

Things Hospice Innovators Need To Know (THINK) program developed

to train VHCF employees and volunteers on diversity issues and how to approach individuals of various cultures and religious (African

American, Hispanic/Latino American, Jewish American and Muslim Americans).

VHCF states the Subdistrict 6B governing body will implement a Quality Improvement Program aimed at identifying patient care quality areas that

need improvement, ensuring that care provided is appropriate to patient needs, and to revise procedures as necessary. The applicant provides a description of the Quality Improvement programs assessment and

monitoring components. The applicant reviews the conditions predicated upon award related to

quality of care, and adds an additional summary of the training, recruitment, benefits, and management system designed to achieve the

highest levels of employee performance to ensure quality of care and patient satisfaction.

VITAS serves the following hospice service areas in Florida: 4A, 4B, 7A, 7B, 7C, 8B, 9C, 10 and 11. Agency records indicate that VHCF has 11

substantiated complaints for the three year period ending December 13, 2013.

VHCF Substantiated Complaint Categories in the Past 36 Months

Complaint Category Number Substantiated

Quality of Care/Treatment 5

Resident/Patient Rights 2

Resident/Patient/Client Assessment 2

Administration/Personnel 1

Nursing Services 1 Source: Agency for Health Care Administration complaint records.

The Agency publishes results for a statewide Hospice Provider Family Satisfaction Survey, available at the Agency website: http://www.floridahealthfinder.gov/Hospice/CompareHospiceStats.aspx.

http://www.floridahealthfinder.gov/Hospice/CompareHospiceStats.aspx


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The most recent results of this survey range from January 2013 through March 2013. VHCF’s three licensed hospices in Florida attained a five-

star rating on each of the five questions in the survey. Respondents ranged from a low of 141 to a high of 176. The five-star rating is the

highest attainable and indicates respondents were 90 to 100 percent satisfied with the hospice’s performance.

VHCF participates in a statewide patient/family satisfaction survey, complied by the Department of Elder Affairs (DOEA). The survey results are indicated as percentages for three Outcome Measures—1, 2 and 2A.

Per the DOEA’s 2013 Report on Hospice Demographic and Outcomes Measures, issued October 2013 (for calendar year 2012), family and

patient satisfaction survey results on VHCFs performance are shown below:

Vitas Healthcare Corporation of Florida (CON #10207)

2012 Outcome Measure Results Hospice

Outcome Measure Number of Patients 1 2 2A

VHCF-North Miami Beach 85% 94% 96% 6,787

VHCF-Melbourne 80% 94% 98% 6,454

VHCF-Boynton Beach 86% 94% 96% 7,335

State 84% 95% 97% 116,242 Source: DOEA, 2013 Report on Hospice Demographics and Outcomes Measures, issued October 2013 for calendar year 2012, pages 8-10. Note: Florida hospices reported pain level data for 53,097 patients at the time of admission and 8,966

patients reported severe pain on admission. There were 18,958 survey responses to Outcome Measure 2 and 25,489 responses to Outcome Measure 2A. Number of responses by hospice was not provided.

As shown in the table above, two of the three VHCF hospices exceed and

one is below the state average for Outcome Measure 1, all three are below the state average for Outcome Measure 2, and one exceeds and two are below the state average for Outcome Measure 2A.

c. What resources, including health manpower, management

personnel, and funds for capital and operating expenditures, are available for project accomplishment and operation? ss. 408.035(1)(d), Florida Statutes.


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, a Florida developmental stage corporation, provided audited financial statements for the period ending December 31, 2012 of

their parent company. These statements were analyzed for the purpose of evaluating the applicant’s ability to provide the capital and operational


35

funding necessary to implement the project. The applicant did not include the previous two years of the parent’s audited financial

statements, which is required by s. 408.037(2)(c) Florida Statutes.

Short-Term Position: The balance sheet does not indicate what items are current and which are long-term. Because of this, the Agency cannot determine the position

of the applicant for measurements that require current assets or liabilities for their calculation. The parent had a negative cash flow from operations from the most recent year of operations. Based on the limited

data provided by the applicant it appears that the applicant has a weak short-term position (see Table 1).

Long-Term Position: The balance sheet does not indicate what items are current and which

are long-term. Because of this, the Agency cannot determine the position of the applicant for measurements that require long-term assets or

liabilities for their calculation. The ratio of net assets to total assets of 0.16 is below average, a weak position. The ratio of cash flow to total assets of negative 17.4 percent is below average and a weak position.

The most recent year had an operating gain of $46.6 million, which resulted in a 21 percent operating margin. Overall, the applicant has a moderately weak long-term position (see Table 1).

Capital Requirements:

Schedule 2 indicates total capital projects of $368,503 which consist of the CON subject to this review and estimated capital expenditures in year two.

Available Capital: Funding for this project will be provided by the applicant’s parent. The

applicant has cash and cash equivalents of $23.8 million. The applicant appears to have sufficient capital to fund this project and the entire

capital budget. Conclusion: Funding for this project should be available as needed.


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TABLE 1

Greystone Hospice of District 6B, LLC – CON application #10206

12/31/2012

Current Assets (CA) $0

Cash and Current Investment $23,879,897

Total Assets (TA) $998,703,704

Current Liabilities (CL) $0

Total Liabilities (TL) $834,754,312

Net Assets (NA) $163,949,392

Total Revenues (TR) $221,720,883

Interest Expense (IE) $18,521,581

Operating Income (OI) $46,598,448

Cash Flow from Operations (CFO) ($173,549,452)

Working Capital $0

FINANCIAL RATIOS

12/31/2012

Current Ratio (CA/CL) N/A

Cash Flow to Current Liabilities (CFO/CL) N/A

Long-Term Debt to Net Assets (TL-CL/NA) N/A

Times Interest Earned (OI+IE/IE) 3.5

Net Assets to Total Assets (NA/TA) 16.4%

Operating Margin (OI/TR) 21.0%

Return on Assets (OI/TA) 4.7%

Operating Cash Flow to Assets (CFO/TA) -17.4%

VITAS Healthcare Corporation of Florida (CON application #10207): 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, a Florida for-profit corporation, provided audited financial statements for

the periods ending December 31, 2012 and 2011. These statements were analyzed for the purpose of evaluating the applicant’s and parent’s ability to provide the capital and operational funding necessary to

implement the project.

Short-Term Position: The applicant’s current ratio of 1.4 indicates current assets are slightly greater than current obligations, but is below average and a slightly weak

position. The ratio of cash flow to current liabilities of 2.3 is above average and a strong position. Overall, the applicant has an adequate

short-term position (see Table 1).


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Long-Term Position: The ratio of long-term debt to net assets of 0 indicates the applicant has

no long term debt, a strong position. The ratio of cash flow to assets of 14.0 percent is above average and a strong position. The most recent

year had an operating income of $69,907,423 which resulted in a 16.8 percent operating margin. Overall, the applicant has a strong long-term position (see Table 1).

Capital Requirements: Schedule 2 indicates total capital projects of $20,241,888 which consist

of the CON subject to this review and estimated capital expenditures.

Available Capital: Funding for this project will be provided by the applicant. Based on our review, the applicant has available working capital of $7.9 million and

cash flow from operations of approximately $42.5 million. The applicant appears to have sufficient capital to fund this project and the entire

capital budget. Conclusion: Funding for this project should be available as needed.

TABLE 1

VITAS Healthcare Corporation of Florida - CON application #10207

Applicant Applicant

03/31/12 03/31/11

Current Assets $26,690,606 $23,144,885

Cash and Current Investment $0 $0

Total Assets $303,880,003 $260,917,116

Current Liabilities $18,838,577 $20,364,278

Total Liabilities $20,179,166 $20,364,278

Net Assets $283,700,837 $240,552,838

Total Revenues $417,013,508 $382,024,540

Interest Expense $0 $0

Excess of Revenues Over Expenses $69,907,423 $66,317,556

Cash Flow from Operations $42,499,500 $63,467,807

Working Capital $7,852,029 $2,780,607

FINANCIAL RATIOS

12/31/12 12/31/11

Current Ratio (CA/CL) 1.4 1.1

Cash Flow to Current Liabilities (CFO/CL) 2.3 3.1

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

Times Interest Earned (NPO+Int/Int) N/A N/A

Net Assets to Total Assets (NA/TA) 93.4% 92.2%

Total Margin (ER/TR) 16.8% 17.4%

Return on Assets (ER/TA) 23.0% 25.4%

Operating Cash Flow to Assets (CFO/TA) 14.0% 24.3%


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d. Will the proposed project foster competition to promote quality and cost-effectiveness? ss. 408.035(1) (e) and (g), Florida Statutes.

The following applies to both applicants.

This application is for a new hospice agency to be located in Service Area 6B which currently has three 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 4.0 percent of its patient days from self-pay/commercial insurance payers and 96.0

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 discernible positive impact on price based competition to promote cost

effectiveness. As providers offer new or enhanced services to patients and families as a means to compete on quality measures, cost

effectiveness would be impacted since the new or enhanced services would be offered despite the large percentage of fixed priced government payers. In other words, the potential exists for new or enhanced services

to be provided for the same federal and state dollars. Conclusion: This project is not likely to result in price-based competition.

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

proposal? ss. 408.035 (1)(f), Florida Statutes.

Greystone Hospice of District 6B LLC (CON application#10206):

For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 92.7 percent,

Medicaid at 3.3 percent, commercial insurance at 1.0 percent and self-pay at 3.0 percent.

The applicant indicated in the notes to Schedule 7 that the services it intends to provide are routine home care, continuous care, inpatient respite care and acute inpatient care, for which the Department of Health

and Human Services sets rates. The federal rates were calculated for Polk County, Florida Wage Index for Medicare Hospice payments of


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0.8432 and inflated through December 2016. The average price adjustment factor used was 2.71 percent per year based on the new CMS

Market Basket Price Index as published in the 3rd Quarter 2013 Health Care Cost Review.

Estimated patient days for each level of service from the notes to Schedule 7, year two were multiplied by the calculated reimbursement

rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then compared to the applicant’s estimated gross revenue. The results of the

calculations are summarized in Table 2 below.

The applicant’s projected gross revenue was 7.5 percent, or $290,137 less than the calculated gross revenue. Operating profits from this project are expected to increase from negative $95,570 for year one to

$525,607 for year two.

The applicant offered a few conditions to its proposed hospice program. None of the conditions appear to have a material financial impact to the projections.

Conclusion: This project appears to be financially feasible.

HOSPICE REVENUE TABLE 2

CON application #10206 Greystone Hospice of District 6B, LLC Wage Index for Polk County(0.8432)

Wage Component

Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $107.37 0.8432 $90.53 $48.89 $139.42

Continuous Home Care $626.05 0.8432 $527.89 $285.09 $812.98

Inpatient Respite $91.98 0.8432 $77.56 $77.94 $155.50

General Inpatient $444.35 0.8432 $374.68 $249.84 $624.52

Payment Rate

Inflation Factor

Year Two

Inflation Adjusted Amount

Patient Days Year 2,

December 31 -2016

Calculated Gross

Revenue

Routine Home Care $139.42 1.061 $147.94 22,547 $3,335,542

Continuous Home Care $812.98 1.061 $862.61 496 $427,856

Inpatient Respite $155.50 1.061 $164.99 56 $9,240

General Inpatient $624.52 1.061 $662.65 582 $385,661

Total 23,681 $4,158,298

From Schedule 7 $3,868,161

Difference

-$290,137

Percentage difference -7.50%


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VITAS Healthcare Corporation of Florida (CON application #10207):

For year two of operations, the applicant projected the following percentage of total patient days by group: Medicare at 92.0 percent,

Medicaid at 4.5 percent, charity at 1.5 percent, and commercial insurance at 2.0 percent.

The applicant indicated in the notes to Schedule 7 that the services it intends to provide are routine home care, continuous care, and inpatient respite care, for which the Department of Health and Human Services

sets rates. The federal rates were calculated for Polk County, Florida Wage Index for Medicare Hospice payments of 0.8432 and inflated

through March 2016. The average price adjustment factor used was 2.68 percent per year based on the new CMS Market Basket Price Index as published in the 3rd Quarter 2013 Health Care Cost Review.

Estimated patient days for each level of service from the notes to

Schedule 7, year two were multiplied by the calculated reimbursement rate for that service in order to estimate the total revenue that would be generated by that number of patient days. The results were then

compared to the applicant’s estimated gross revenue. The results of the calculations are summarized in Table 2 below.

The applicant’s projected gross revenue was 86.2 percent, or $4,332,374, less than the calculated gross revenue. Operating profits from this

project are expected to increase from negative $777,896 for year one to $1,669 for year two.

Conclusion: This project appears to be financially feasible.


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HOSPICE REVENUE TABLE 2

CON application #10207 VITAS Healthcare Corporation of Florida

Wage Index for Polk County(0.8432)

Wage

Component Wage Index

Adjusted Wage

Amount

Unadjusted

Component

Payment

Rate

Routine Home Care $107.37 0.8432 $90.53 $48.89 $139.42

Continuous Home Care $626.05 0.8432 $527.89 $285.09 $812.98

Inpatient Respite $91.98 0.8432 $77.56 $77.94 $155.50

General Inpatient $444.35 0.8432 $374.68 $249.84 $624.52

Payment Rate

Inflation

Factor Year Two

Inflation

Adjusted Amount

Patient Days

Year 2, March 31, 2016

Calculated

Gross Revenue

Routine Home Care $139.42 1.040 $145.02 21,349 $3,096,038

Continuous Home Care $812.98 1.040 $845.60 6,212 $5,252,897

Inpatient Respite $155.50 1.040 $161.74 286 $46,257

General Inpatient $624.52 1.040 $649.58 1,485 $964,628

Total 29,332 $9,359,821

From Schedule 7 $5,027,447

Difference

-$4,332,374

Percentage difference -86.17%

f. Are the proposed costs and methods of construction reasonable? Do

they comply with statutory and rule requirements? ss. 408.035(1)(h), Florida Statutes.

Each of the co-batched applicants is requesting approval to establish a new hospice program. 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(1)(i), Florida Statutes. Greystone Hospice of District 6B LLC (CON application #10206) is a

newly formed entity and does not have any operational history. However, the applicant states intent to provide care to all patients in the service area, regardless of ability to pay. In order to assist in meeting the needs

of residents in HSA 6B, the applicant conditions approval of the project on the establishment of a new non-profit charitable foundation, funded

through one million dollars in contributions from Greystone & Co., Inc. during the initial five-year period of hospice program licensure, with at least $200,000 contributed within 90 days of initial licensure of the


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proposed hospice program, and will distribute funds based on local needs as demonstrated through registered not-for-profit organizations in

the community.

Schedule 7A shows Greystone Hospice of District 6B LLC’s patient days by payor as follows: 3.3 percent Medicaid patient days for years one and two of operations, and 3.0 percent self-pay for the first two years of the

project. VITAS Healthcare Corporation of Florida (CON application #10207)

states it has a long history of providing services to Medicaid and the medically indigent and proposes to provide such services in 6B as well.

Schedule 7A shows VHCF’s patient days by payor as follows: 4.5 percent Medicaid patient days for years one and two of operations, and 1.6 and

1.5 percent charity care for years and two respectively of the proposed project.

F. SUMMARY

A fixed need pool was published for a new hospice program in Hospice Service Area 6B (Hardee, Highlands and Polk Counties). The applicants

are applying in response to published need.

Greystone Hospice of District 6B LLC (CON application #10206) is proposing total project costs of $318,113 with year one operating costs of $1,991,617 and year two costs of $3,779,259.

The applicant’s Schedule C proposes six conditions (see pages 6-8 of this report).

VITAS Healthcare Corporation of Florida (CON application #10207) is

proposing total project costs of $893,468 with year one operating costs of $246,092,247 and year two costs of $255,119,334.

Schedule C includes three broad condition categories which encompass multiple specific conditions (see pages 8-12 of this report).


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Need/Access:

Each applicant is responding to published need for a new hospice

program. Each co-batched applicant provided evidence that they have local

support for their proposals to enter the service area. Both applicants provided letters of support from healthcare providers within the hospice service area.

VHCF submitted the most letters of support from within 6B including

three letters (one hospital and two nursing homes) willing to enter into contractual arrangements. Greystone Hospice also submitted support letters from providers within 6B, including one nursing home willing to

enter into contractual arrangements. VITAS letters of support were more numerous and expressed a better understanding of the service area than

those for Greystone. Both applicants have agreed to measurable conditions, if awarded the

CON, to ensure that its proposed program offers improved access to hospice care and services in HSA 6B. However, VHCF submitted the most comprehensive list of conditions and programs predicated upon

award.

Both applicants condition their application on the provision of non-core services; however, Greystone Hospice does not specify any details of services provided by the condition, while VHCF conditions to a fully

explicated list of services.

Both applicants will open offices in Hardee and Polk Counties. VHCF is

the only applicant committing to an office location in Highlands County.

The Agency’s need methodology that resulted in published need for a new program in Subdistrict 6B showed the projected number of admissions minus the current number of admissions for the January 2015 planning

horizon as 468. Greystone Hospice projects admissions of 240 and 372 for years one and two of the proposed project; VHCF proposes 255 and

482 admissions. By a margin of 15 year one admissions and 110 year two admissions, VHCF proposes the largest program to address this need.

VITAS proposes an early start-up date for the hospice program if receiving final CON approval. The applicant provided evidence that

VITAS has opened two new CON-approved programs since 2008, with start-up times of 22 and 46 days, respectively.


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Quality of Care:

Agency licensure records indicate during the three-year period ending on

December 6, 2013, the 18 Greystone Healthcare Management Corporation affiliated skilling nursing homes in Florida had 64 substantiated complaints.

Agency records indicate that VHCF has 11 substantiated complaints for the three-year period ending December 13, 2013.

A single complaint can encompass multiple complaint categories.

VITAS is a well-established hospice program, while Greystone does not operate hospice programs at this time. VITAS presented a more detailed

description of its ability to provide quality hospice care than Greystone.

Financial Feasibility/Availability of Funds: Greystone Hospice of District 6B LLC (CON application #10206)

failed to provide the parent’s previous two fiscal years’ operation. Based on the limited data provided, it appears that the applicant has a weak short-term position.

Overall, the applicant has a moderately weak long-term position.

The applicant’s projected gross revenue was 7.5 percent, or $290,137 less than the calculated gross revenue. Operating profits from this


VITAS Healthcare Corporation of Florida (CON application #10207) has an adequate short-term position and a strong long-term position.

The applicant’s projected gross revenue was 86.2 percent, or $4,332,374, less than the calculated gross revenue. Operating profits from this


Both applicants: Funding for this project should be available as needed.

This project appears to be financially feasible.


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Medicaid/Charity Care:

Greystone Hospice of District 6B LLC (CON application #10206): Schedule 7A shows 3.3 percent Medicaid patient days for years one and

two of operations, and 3.0 percent self-pay for the first two years of the project.

VITAS Healthcare Corporation of Florida (CON application #10207): Schedule 7A shows 4.5 percent Medicaid patient days for years one and two of operations, and 1.6 and 1.5 percent charity care for years one and

two respectively of the proposed project.

G. RECOMMENDATION

Approve CON #10207 to establish a new hospice program in Hospice Service Area 6B. The total project cost is $893,468 with year one

operating costs of $246,092,247 and year two costs of $255,119,334. CONDITIONS:

1. The intent of VHCF is to provide high quality, cost-effective and

coordinated services for its patients/families and the community-

at-large. VHCF will make a meaningful contribution to Subdistrict 6B to those persons with non-cancer illnesses in need of hospice

care and hospice patients in need of continuous care. This will be accomplished through its proven experience and programming and its successful operating model, and assured via the conditions

proposed by VHCF. Please note that we have not listed as conditions services and

procedures that are required by state and federal law because we understand the conditions in a CON application are intended to be

actions the applicant commits to voluntarily. In addition to these conditions, VHCF will comply with all state and federal laws. VHCF commits to the following core service, non-core service and

operational/programmatic conditions identified below and commits to meet all of the requested reporting requirements and time

frames as defined in Chapter 59C-1.013 and 59C-1.021, Florida Administrative Code.


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

o The first population subgroup is defined as hospice patients in need of continuous care: VHCF will provide at least 2.4 percent

of its total patient days as continuous care by year two. This will be measured via a signed declaratory statement by VHCF which may be supported by review of patient day reports by

type and month produced by VHCF. o The second population subgroup is defined as hospice patients

with diagnosis other than cancer. VHCF will offer specific

programs and make targeted outreach efforts to serve patients with non-cancer diagnoses. This will be measured via a signed

declaratory statement by VHCF which may be supported by review of admission reports by patient diagnosis produced by VHCF.

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

provision it will meet or exceed the following quality and patient satisfaction indicators:

o Pain Control: On the first day of hospice care responsive patients will be asked to rate their pain on the 0-10 World Health Organization pain scale (severe pain to worst pain

imaginable). A pain history will be created for each patient. These measures will be recorded in VHCF’s proprietary

information management system, VITAS Exchange (or “Vx”) via a telephone call using the telephone keypad for data entry. Seventy percent or more of patients who report severe pain

(seven-10) will report a reduction to five or less within 48 hours after admission. Florida Statutes 400.60501 requires only a 50 percent reduction in 96 hours, so this commitment exceeds

Florida statutory requirements and is a significant commitment to quality care.

o Death Attendance: A VHCF staff member or volunteer will attend at least 90 percent of all deaths to ensure patients do not die alone. This will be measured via a signed declaratory

statement by VHCF which may be supported via review of patient medical records.

o Patient Family Satisfaction: VHCF will achieve an overall patient satisfaction score of 90 percent or above on the patient’s family evaluation of care while under the care of VITAS. This is

determined by a mail-in survey sent by VHCF to the patient’s family and measured by averaging all scores.


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o Discipline Specific Satisfaction: VHCF will achieve an overall Registered Nurse satisfaction score of 90 percent or above on

patient’s family satisfaction with the VHCF nurse while under the care of VITAS. This is determined by a mail-in survey sent

by VHCF to the patient’s family and measured by averaging all scores.

o Pet Therapy: Implement a pet therapy program to begin

immediately. PetPals is a program where screened dogs visit shut-ins, nursing homes, assisted living facilities, adult day care center and Alzheimer patients. This program offers a visit

with a pet to those in the community who may respond to the love and comfort of a pet therapy dog. VHCF has an affiliation

with the Central Florida Toy Dog Club which has sister organizations throughout the state. Volunteers and their pets are trained to assist patients and their families in any setting.

4. Other Conditions: VHCF has conditioned the application on the

provision it will meet or exceed the following operational and programmatic indicators:

o Establish satellite hospice offices in Hardee County and Highlands County during the first year of operation. Establish a second hospice office in Polk County during the second year

of operation. o Create a Mobile Hospice Education Unit in the first year of

operation. The Mobile Hospice Education Unit will travel to various community centers, health care facilities and shopping centers in the area to provide hospice outreach and education.

The Mobile Hospice Education Unit staff will provide pamphlets, brochures and firsthand information about hospice services.

o Implement a TeleCare Program consisting of 24/7 nurse

availability to begin immediately. o Establish a Local Ethics Committee to begin upon certification,

as discussed in Schedule B Section E2 of this application. o Implementation of CarePlanIT, a handheld bedside clinical

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

CarePlanIT is discussed in Schedule B Section E2. o VHCF will work with Palliative Medical Associates of Florida to

implement its palliative care program in Subdistrict 6B within one year of licensure. This program is discussed in Schedule B, Section E3(d). As indicated in the letter included from Mary

Zalaznick, Senior Vice President and Administrator of Palliative Medical Associates of Florida, in TAB 11, this will not require any monetary commitment from VHCF.

o Provide palliative radiation, chemotherapy and transfusions as appropriate for treating symptoms.


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o Commit to having every patient being assessed by a physician within 24 hours of admission to the hospice. Medical directors

provide patient visits in their residence. o Medical directors must be board-certified in hospice or palliative

care medicine, or apply for board-certification within five years of employment.

o RNs are encouraged to become certified in hospice and palliative

care nursing. By the second year of operation, 50 percent of all supervisory nurses will attain such certification.

o Masters of Divinity or equivalent graduate degree from an

accredited seminary or theological school required for chaplains.

o Social workers are Master’s level or licensed clinical social workers.

o Although bereavement services are generally provided to the

family for one year after the death of the patient, services will be available beyond one year, if needed.

o VHCF agrees that it will not engage in any fundraising events or campaigns to obtain charitable contributions from residents of the subdistrict. VHCF will respond to inquiries from persons

seeking to make charitable contributions for hospice services with information on relevant 501(c)(3) organizations that benefit Florida residents.

o Establish a clinical Pastoral Education program to begin immediately. The program description is found in the

application’s Tab 10. o VITAS, as the parent company of VHCF, commits to spend

$50,000 for five years, or a total of $250,000 through

institutions of higher education, disease advocacy groups and professional associations located in Subdistrict 6B to provide educational content on end-of-life care for degree programs,

continuing professional education and community education. These funds may be used to develop curriculum, provide

scholarships, underwrite seminars and conferences, and fund faculty or research positions. This condition will be measured by a signed declaration by VHCF and documentation of the

expenditure and use of funds.

Deny CON #10206.


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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration adopted the recommendation contained herein and released the State Agency Action Report.

DATE:

James B. McLemore

Health Services and Facilities Consultant Supervisor Certificate of Need

Jeffrey N. Gregg

Director, Florida Center for Health Information and Policy Analysis