STATE AGENCY ACTION REPORTahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10095.pdf(CON #10095) the...

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Haven Behavioral Services of Florida, LLC/CON #10094

652 West Iris Drive

Nashville, Tennessee 37204

Authorized Representative: Kirk McConnell, Esq.

(615) 250-9500


652 West Iris Drive

Nashville, Tennessee 37204

Authorized Representative: Kirk McConnell, Esq.

(615) 250-9500

2. Service District/Subdistrict

District 3 – Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist,

Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter,

Suwannee and Union Counties

B. PUBLIC HEARING

A public hearing was not held or requested on the applicant‟s

(CON #10094) proposed 24-bed adult inpatient psychiatric hospital in

Hernando County. However, a public hearing was requested regarding

(CON #10095) the applicant‟s proposed 26-bed adult inpatient

psychiatric hospital-in-a-hospital at Leesburg Regional Medical Center-

North in Lake County. The public hearing was held on Wednesday,

October 27, 2010, at WellFlorida Council, Inc.‟s main conference room in

Gainesville, Florida. Kim Gokhale, MA, MPH, Associate Planner for

WellFlorida Council, Inc., conducted the hearing.

CON Action Numbers: 10094 & 10095

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Vernon Westrich, President and CEO, Haven Behavioral Healthcare

(parent company of the applicant) stated that Haven has been in

operation for five years and has nine facilities in six different states.

He said that he has worked in behavioral health for over 30 years.

Mr. Westrich stated Haven focuses on specific niches of behavioral health

where they believe there is an underserved population. Haven believes it

can provide a better service since it focuses on one group (geriatric

psychiatric patients) rather than co-mingling multiple groups.

Mr. Westrich stated his organization already operates two hospital-in-a-

hospital all-geriatric psychiatric programs, similar to what is proposed in

the application. As for “why here” and “why this program”, Mr. Westrich

stated that behavioral problems are one of the greatest challenges to

independent living by geriatric patients. He also discussed the aging of

America and services available in the immediate area. Mr. Westrich

stated that while there are capable providers in the area, there is no

dedicated unit for geriatric psychiatric patients and the closest

psychiatric hospital is approximately 35 miles from the proposed site. It

was also stated that geriatric patients have different needs and treatment

than the general population, that co-mingling geriatric patients with non-

geriatric patients probably has a negative impact for all groups involved,

and that co-location with a medical/surgical hospital is an advantage to

at-risk geriatric patient.

Mr. Westrich stated the hospital-in-a-hospital approach also offers

efficiencies and cost-effectiveness, especially in instances where the

geriatric patient may present with undiagnosed medical conditions that

may present unexpectedly and call for immediate medical attention.

Mr. Westrich stated that safety considerations would be better addressed

for the geriatric patients in an all-geriatric environment. He stated that

Haven is very good at coordination and continuum of care, working with

nursing homes, assisted living facilities and home health agencies and

advocacy groups to transition patients appropriately. Mr. Westrich

stated this relieves stress on the system overall and improves the quality

of life of patients and their families. Mr. Westrich believed the proposal

would relieve a burden on Medicaid by allowing a patient more time at

home before institutionalized care is needed and by “not drawing on

Medicaid”. He indicated that the project would probably bring about 50

jobs to the community.

Mr. Westrich indicated that behavioral discharges, among the elderly in

the area, are less than the general population and less than the state

overall and less than the country. Mr. Westrich stated he believed this is

not because there is no need but that possibly there is no specific

resource to reach this population and so people do the best that they can


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to accommodate the need. He also stated the project would be “an

important new cog in the wheel” for the elderly. Mr. Westrich noted

letters of support from physicians, assisted living facilities, nursing

homes, Agency on Aging representatives and attorneys that deal with the

elderly concerning competency hearings.

Nancy Stokes, Vice President of Clinical Services, Haven Behavioral

Healthcare addressed Haven staff competency, training, life cycle

regimens, specialized programs tailored to address such issues as

decreased vision, decreased hearing and decreased mobility. Ms. Stokes

stated decreased awareness puts elderly patients at risk for increased

falls and that Haven has programs designed to address that risk, using

fall protocols and fall tracking. Ms. Stokes also stated that more than 80

percent of the patients in Haven‟s two geriatric psychiatric hospitals are

70 years of age or older. In addition to nurses and certified nursing

assistants, Ms. Stokes discussed that having pharmacists at every site is

invaluable and that their social workers have a focus on the elderly.

Ms. Stokes stated that one of Haven‟s objectives is to never send a

patient to an emergency room because direct admission is preferred.

She indicated that efforts are made to make the Haven environment look

home-like and not institutionalized.

Patricia Leininger, stated that she is a Professional Guardian for Lake

and Sumter Counties and a representative of the Mid Florida

Guardianship Association. Ms. Leininger stated her support for the

project. She indicated she had spoken to assisted living providers,

nursing homes and guardians in the area and that help is needed.

Ms. Leininger stated evaluation time is often short and placement

options are limited in the current situation and the project would help

relieve those challenges.

Steven Grigas of Akerman Senterfitt, Attorneys at Law, on behalf of

LifeStream Behavioral Health Centers, Inc., stated his opposition to the

project. Mr. Grigas stated that one of the fundamentals of certificate of

need policy is an allocation of resources where there is proven need and

that LifeStream believes need is not proven for this project. Mr. Grigas

further stated a bed need of seven, as issued by the Agency, is

“generous”. He pointed out the project would produce almost four times

the bed need issued by the state. When considering weighing and

balancing all required statutory criteria to determine need, Mr. Grigas

stated the facts and circumstances do not support a legitimate need for

the project and stated bed supply is ample among the existing district

adult psychiatric facilities to meet need. Mr. Grigas also stated no

evidence has been shown that quality of care is an issue that would be

addressed by the project, which would in fact duplicate services already


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available and in ample supply within the district. Mr. Grigas continued

that the nursing shortage in the area would burden existing providers

and ultimately reduce quality of care, if the project were to be approved.

Mr. Grigas stated that a not normal circumstance does not exist to

warrant the project.

Patti Greenberg, Consultant, National Healthcare Associates, Inc. on

behalf of LifeStream Behavioral Health Centers, Inc. gave an overview of

her in-depth findings of CON application #10095 as documented in her

written critique. Ms. Greenberg stated that the applicant proposed or

suggested there were not normal circumstances in the community to

support the project but these circumstances were not presented in the

application. She indicated there were no program access issues, supply

was understated and no geographic access issues, with LifeStream‟s

facilities being two miles from the proposed site. Ms. Greenberg also

stated there were no financial access issues and no cultural access

issues.

She stated that the applicable discharge rate in the area should not

necessarily mirror that of the nation overall, especially considering the

more affluent population in Lake and Sumter Counties because a poorer

population would tend to utilize mental health services more than an

affluent one. Ms. Greenberg stated that this greater affluence was not in

the applicant‟s need analysis. Ms. Greenberg stated discharged

populations were double-counted which produced an inaccurately higher

bed need. Ms. Greenberg pointed out the average length of stay (ALOS)

days are overestimated by the applicant (approximated at about 15 days

rather than the more current 7.8 days statewide based on current

utilization) and that this inaccurately doubles the bed need.

Ms. Greenberg continued that Haven found assisted living and nursing

home facilities in the area were underserved based on the applicant‟s

Phoenix and Denver programs. However, Ms. Greenberg stated that

services in Lake and Sumter Counties should not necessarily be like

those in the applicant‟s Phoenix and Denver programs. Ms. Greenberg

also stated that Agency discharge data does not distinguish between

discharges to assisted living as opposed to home and that the applicant

misinterpreted Agency data in this regard. She indicated that the

applicant did not consider that LifeStream has outpatient services in The

Villages area with three full-time psychiatrists on staff and that other

inpatient adult psychiatric providers in the district have geriatric

programs that can accommodate need.

Ms. Greenberg also criticized the applicant‟s use of what she considered

misleading or simply incorrect statistics; that the applicant relied on

articles that go back to 1999 and 1992 when there is more current


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published research that talks about use rates for inpatient care being on

the decline. Ms. Greenberg stated the applicant‟s exclusionary criteria

indicates the program is for patients age 55 and older but that the

applicant conditions for only geriatric patients so it should be for age 65

and older. Ms. Greenberg further indicated that the site of the project,

Leesburg Regional Medical Center-North, is not a full service

medical/surgical hospital and so patients in need of services at a

medical/surgical hospital would have to be transferred. Ms. Greenberg

also commented the application did not meet the Class III minimum of

30 beds (CON minimum size is 40 beds). She noted the applicant talked

about referral sources in the application but contends that referrals will

be limited because the facility will not be a Baker Act receiving facility.

Ms. Greenberg stated the applicant further misunderstood the Agency

discharge data by concluding that providers in the district do not provide

service to Medicaid and charity care patients. She stated that the

applicant‟s proposed charity care condition will offer little relief to other

providers. Ms. Greenberg stated concern that continuity of care would

be a problem since the applicant does not plan to provide outpatient

services. Ms. Greenberg stated her review indicated the project lacked

short-term and long-term financial feasibility.

Ms. Greenberg noted what she called missing costs - no pharmacist in

the financial schedules though Ms. Stokes had stated all sister facilities

maintain a pharmacist on-site, 28 employees in the financial schedules

though Mr. Westrich had stated approximately 50 employees for the

project and no accounting for interest expense. Ms. Greenberg also

questioned what she said was fewer nurses and technicians as a patient

ratio compared to other providers in the district and if this would

challenge quality of care and financial feasibility.

Howard Weiner, Vice President for Administration, LifeStream Behavioral

Health Centers, Inc., stated LifeStream has been in the community since

1967. LifeStream provides mental health and substance abuse services

to the community whether the patient can afford it or not and that

Lifestream has received numerous awards and grants to address a wide

range of mental health populations in the area. Mr. Weiner stated

LifeStream is the only Baker Act Receiving Facility in Lake and Sumter

Counties1 and also the only Marchman Act Receiving Facility.

Mr. Weiner indicated that last year approximately half of LifeStream

patients age 65 and older were presented by law enforcement under a

Baker Act. He also stated that LifeStream provides after-care (post-

1 LifeStream Behavioral Center, Inc. is a Baker Act Receiving Facility, with designation by the Florida Department of Children and Families (DCF), with no other provider so designated in Lake and Sumter Counties, per DCF. http://www.dcf.state.fl.us/programs/samh/MentalHealth/laws/recfac.pdf.

http://www.dcf.state.fl.us/programs/samh/MentalHealth/laws/recfac.pdf


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discharge) psychiatric services throughout Lake and Sumter Counties,

including among other services two group homes for geriatric clients

only, with approximately 80 residential beds scattered throughout the

two counties. Mr. Weiner stated LifeStream is a community mental

health center. He further stated the project is not needed and that about

25 percent of LifeStream‟s patients are indigent. Mr. Weiner concluded

that the project could take patients and hurt LifeStream‟s ability to treat

the total community, including the indigent.

Bob Sharpe, MSW, President and CEO, Florida Council for Community

Mental Health, Inc., and former Director, Florida Medicaid Program,

stated that Lifestream is a member of his organization, which has 65

members who are all non-profits with strong community ties.

Mr. Sharpe stated that if the project was approved, the result would be a

loss of revenues for LifeStream which would make it more difficult for

LifeStream to provide the essential and wide range of services it currently

provides. Mr. Sharpe indicated for many patients there are suitable

outpatient alternatives to a 15-day ALOS at the proposed site. He also

expressed concern for patient continuity of care because Haven does not

propose to provide outpatient services.

Susan Smith of Smith and Associates, Attorneys and Consultants at

Law, on behalf of The Vines reiterated some comments made by previous

speakers opposed to the project. Ms. Smith restated the project site is

two miles from Lifestream and stated that LifeStream has less than 70

percent occupancy, Haven does not plan to be a Baker Act Receiving

Facility or Marchman Act Receiving Facility and does not propose a

charity care condition. Ms. Smith stated that, from a regulatory

perspective, a need of seven beds issued by the Agency was a technical

mistake, was not timely challenged and therefore stands. Ms. Smith

stated the Agency‟s seven-bed need is a rebuttable presumption and that

the evidence a seven-bed need was an error would be “allowed to come

in” and would show that there was not a need. Ms. Smith also stated

there is no “not normal circumstance” to warrant the project. Ms. Smith

concluded that approval of the project would punish existing providers

who are managing to keep the target population out of hospitals (in

outpatient settings to the extent practical).

Rich Capiola, MD, (a psychiatrist) and Chief Medical Officer for

Oglethorpe (parent for Springbrook Hospital) stated that there are

recruitment challenges for seeking and retaining qualified staff for a

psychiatric hospital like Springbrook. Dr. Capiola stated the project

would likely drain qualified staff from Springbrook and other systems

meaning facilities in the area would likely struggle with quality of care


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issues due to recruitment and retention difficulties brought on by project

approval.

John Sannuto, Administrator, Springbrook Hospital, indicated his facility

is a freestanding 66-bed psychiatric hospital and Baker Act Receiving

Facility, located in Hernando County. Mr. Sannuto stated that

Dr. Capiola had touched on his major concerns.

Scott Price, Director of Business Development, The Vines, indicated his

facility is a freestanding 98-bed psychiatric hospital (48 beds on the

adult unit), located in Marion County. Mr. Price stated The Vines is a

Baker Act Receiving Facility that has 14 beds in the adult unit

designated for older adults (55 years of age and older) and that a third of

the patients served by The Vines are from Lake and Sumter Counties.

Mr. Price indicated his facility offers several psychiatric services to the

community such as teen suicide prevention among others and that The

Vines is the only statewide inpatient psychiatric placement (SIPP)

provider, for youth and adolescents, in District 3. Mr. Price stated there

is no deficit for psychiatric services for the elderly in District 3 and The

Vines recently opened outpatient services in The Villages area for this

population. Mr. Price stated that front-line staff and clinical staff are

difficult to retain and that while registered nurses are available, few have

psychiatric capabilities or experience and that project approval would

negatively impact his facility. He also stated that the loss of call coverage

or one of The Vines‟ psychiatrists would greatly deplete quality of care at

his facility. Mr. Price commented that the project would draw from the

same patient base and as a non-Medicaid provider would have negative

financial impact on The Vines and other providers in the area.

Ed Witek, consultant and registered pharmacist, on behalf of the

applicant, Haven Behavioral Services of Florida, LLC, stated he had

written “well over 100” of these types of applications, that no effort would

be made to rebut previous statements and that providers in the area do a

good job of providing psychiatric services. Mr. Witek stated what is

proposed is a specialized psychiatric program (seeking patients largely

from nursing homes and assisted living facilities) and that providers in

the area do not specifically serve the elderly like the applicant would.

Mr. Witek stated the particular patient base sought in the project is

Medicare patients and that many of the statistics provided by those

opposed to the project are about the general psychiatric patient

population and are not elder-specific. Mr. Witek also stated that if the

Agency‟s decision goes to administrative hearing, that there will be cross

examination, depositions and discovery and that evidence will have to be

proved up.


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Vernon Westrich, President and CEO, Haven Behavioral Healthcare

stated he may have mistaken Leesburg Regional Medical Center-North‟s

particular licensure but that there would be medical resources nearby.

Mr. Westrich also stated that general adult patients and geriatric

patients may be getting treated similarly regarding ALOS and not

specific, like his project would. He further stated the geriatric psychiatric

patient population has very specific need protocols that differ from those

of general population and that “one size fits all” does not result in the

best care for this population. Mr. Westrich refuted that the applicant

lacks financial means to move the project forward. In closing, Mr.

Westrich stated that he believed the elderly deserve the best and most

appropriate care for their particular psychiatric needs just as much as

any other population.

Letters of Support

Haven Behavioral Services of Florida, LLC (CON #10094) submitted

16 signed letters of support for its Brooksville project (CON application

#10094, Attachment E – Letters of Support). All except four that were

not dated, were signed during September 3 – 22, 2010. Thirteen letter

writers were from District 3 and three had a District 5, Pasco County

address. These letters are described briefly below.

Three physicians submitted letters: Melissa Asuncion, MD, with

Geriatric Medical Associates, Inc., James Cummings, MD, CMD with

Physician Partners Network, P.A. and Michael Hall, MD, with Wildwood

Medical Center. These physician support letters were of a form letter

variety and broadly stated a need for the proposed project.

Some of the non-physician support letters included: Jerald Leary,

Administrator, Osprey Point Nursing Center (Sumter County); Derek

Ganary, Administrator, Consulate Healthcare of New Port Richey (Pasco

County); Terence McCarthy, President, Forest Oaks (Alachua County)

and Stephen Webber, Executive Director, Spring Hill Health &

Rehabilitation Center (Hernando County). These senior health care

facility executives expressed support for the project, with particular note

of a need for the geriatric psychiatric services the applicant proposes. Letters of Opposition

The Agency received six letters of opposition to CON #10094. All were

signed during October 6 -12, 2010.


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Kranthi Boyapati, MD, Reddy Pasem, MD, Babu Rankupalli, MD and

Ratnasabapathy Sivasekaran, MD, stated that as practicing psychiatrists

in the area (Ocala, Marion County), they know first-hand that there are

high quality mental health inpatient services with beds readily available

in and around Hernando and Lake Counties. These physicians also

stated they have had no difficulties in trying to find available and

accessible beds for their patients. They conclude that if approved, the

project would dilute the availability of experienced, long-standing staff in

the area and that such dilution would burden existing psychiatric

facilities in the area.

Russell Rasco, Chief Executive Officer (CEO) of The Centers (Marion

County) stated that as the CEO of a freestanding psychiatric hospital in

Marion County, he too had first-hand knowledge that there are high

quality mental health inpatient services with beds readily available in

and around Hernando and Lake Counties. Mr. Rasco also stated if

approved, the project would dilute the availability of experienced, long-

standing staff at his facility and that such dilution would burden his as

well as other psychiatric facilities in the area.

Lauren Borowsky, Consultant, National Healthcare Associates, Inc.

submitted a 23-page opposition analysis on behalf of The Vines (Marion

County). The Vines contends that:

• Due to an incorrectly applied occupancy rate, issued by the Agency on

July 23, 2010 the Agency erroneously published need for seven new

inpatient psychiatric beds in District 3 when a net need of zero beds

should have been published. This is correct but it was not timely

challenged.

• Agency rule criterion requires a minimum total capacity of 40

inpatient psychiatric beds but the applicant has proposed a 30-bed

hospital. The applicant‟s 26-bed facility does not meet the rule

criterion, which is one of the factors in evaluating applications.

• If approved, the project would result in a fifth freestanding inpatient

psychiatric hospital in District 3 and would be precluded from

participating in the Medicaid program. The applicant would therefore

compete with other nearby providers to garner admissions from the

same limited, non-Medicaid pool of patients.

• If approved, the project would in effect result in denied access to the

Medicaid population as Medicaid hospital covered services excludes

specialty psychiatric facilities with greater than 50 percent patients

with mental health diseases from participation.


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• Hernando County is home to 10 percent of District 3‟s adult residents

but has nearly 30 percent of the district‟s adult psychiatric beds.

• Springbrook Hospital (District 3, Hernando County), a freestanding

psychiatric hospital, plans to expand its current 61 adult psychiatric

beds by 18 additional adult psychiatric beds.

• Springbrook Hospital has retained an architect to expand the adult

psychiatric bed count and substance abuse beds and the Agency will

be notified of renovations in the very near future.

• If approved, the project (along with the addition of 18 adult

psychiatric beds planned by Springbrook Hospital), would lead to

Hernando County having 42.4 percent of all District 3 beds which is

disproportionate to the population centers.

• Given natural barriers and geographic travel patterns throughout

north central Florida, incremental need in the area will be met by

existing providers.

• There is minimal out-migration of District 3 residents for psychiatric

treatment which is indicative of accessibility within the district.

• In-migration within District 3 is likely because of available beds.

• In-migration within Hernando County from outside District 3 is

significantly greater than the rest of the district, indicating there are

excessive beds in Hernando County sufficient to treat out-of-district

residents.

• District 3 is a net in-migration district, meaning there is not an access

problem where residents must leave the area to obtain inpatient

psychiatric services and in fact, beds are sufficiently available for

persons to travel into District 3 for treatment.

• With the Hernando County discharge use rate at 7.3 percent per

1,000 population (18 years of age and older for MDC 19 in Hernando

County) and the state rate at 7.4 percent, the use rate is right on par

with the state rate, indicating no lack of available and accessible

services.


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• District 3 adult psychiatric hospital services are geographically

accessible to at least 90 percent of the district‟s adult population,

meeting the Agency‟s drive time accessibility criteria, and

• The Vines noted several opposition letters state that this project

would be a duplication of services.

Haven Behavioral Services of Florida, LLC (CON #10095): Haven

submitted 14 letters of support for its Leesburg project (CON application

#10095, Attachment E – Letters of Support). All except six that were not

dated, were signed during September 23 – October 4, 2010. All except

Ms. Leininger‟s were from representatives of local CCRCs, nursing homes

and assisted living facilities. Ada Emmert, Marketing Coordinator at

Waterman Cove stated there is a need for trained professionals who

would provide “rapid response” intensive services for the senior residents

of her facility experiencing severe behavioral issues. Kathy Bachman,

Managing Director at Waterman Cove stated there is a great need for

specialized behavioral health care services in the area and that the only

option is Lifestream, which usually provides only up to a 72-hour stay

and often requires a Baker Act. Ms. Patricia Leininger, a professional

guardian, stated she has often been unsure where to place a ward, since

assisted living may not be able to provide the needed care and that an

age-specific facility would be more appreciated. Terry Haehnel, Campus

Director, Clare Bridge and Sterling House of Leesburg, stated the elderly

with serious behavioral problems can be more appropriately cared for in

a psychiatric facility that is trained in medication management

stabilization along with adequately trained staff. Carole Goggin,

Administrator, Summerfield Suites Assisted Living, stated similar

concerns. Carry French, Owner/ Director, Crown Court Assisted Living

Center, stated that when an adult living center resident becomes severely

disturbed it provides a disproportionately great burden of care on staff

who are also trying to care for other residents with physical disabilities.

The remaining eight letters offered similar explanations as to why they

supported the project. Letters of Opposition

The Agency received 21 letters of opposition to this project. The

Honorable Ginny Brown-Waite, 5th District, Florida, House of

Representatives, Congress of the United States, stated that LifeStream

Behavioral Center, Inc.‟s 46 beds operate at 60 percent occupancy.

Representative Brown-Waite also noted that LifeStream serves as the

Baker Act receiving facility for Lake and Sumter counties. She indicated

that services to the economically disadvantaged “would be reduced if the


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new facility is approved as many insured individuals may choose the

newer facility thereby limiting LifeStream‟s ability to assist the

underserved population”. Representative Brown-Waite concluded that

based on the above, “there is no need for a second facility in the area”.

Most of the opposition letters were of a form letter variety which includes

three sections. These are „unmet need‟ which a discussion of LifeStream

and service to the Lake and Sumter area, „fiscal integrity‟ which contends

that the project will have adverse financial impact on LifeStream and

„scope of service‟ which is a discussion of the full range of services

LifeStream provides compared to the applicant‟s proposal. The form

letters indicate that:

LifeStream Behavioral Center, Inc. already serves the area as a non-

profit community mental health center, a designated Baker Act

facility, and 46-bed psychiatric facility with a 60.0 percent occupancy

rate. Further, approval of the Haven project could result in shortages

in nursing and ancillary staff, which would severely jeopardize

LifeStream‟s ability to continue its present services.

LifeStream is a not-for-profit provider and that the applicant is a for-

profit provider, meaning in many cases, care and treatment would be

at cost to the state.

Lifestream offers a full range of services to the mentally ill while the

applicant would likely not offer a full range of services, leading to

compromised efficiency and effectiveness and increased costs.

Kranthi Boyapati, MD, Reddy Pasem, MD, Babu Rankupalli, MD and

Ratnasabapathy Sivasekaran, MD, stated that as practicing psychiatrists

in the area (Ocala, Marion County), they know first-hand that there are

high quality mental health inpatient services with beds readily available

in and around Hernando and Lake Counties. These physicians also

stated they have had no difficulties in trying to find available and

accessible beds for their patients. They conclude that if approved, the

project would dilute the availability of experienced, long-standing staff in

the area and that such dilution would burden existing psychiatric

facilities in the area.

Russell Rasco, Chief Executive Officer (CEO), The Centers, stated that as

the CEO of a freestanding psychiatric hospital in Marion County, he too

has first-hand knowledge that there are high quality mental health

inpatient services with beds readily available in and around Hernando

and Lake Counties. Mr. Rasco also stated if approved, the project would

dilute the availability of experienced, long-standing staff at his facility

(The Centers-Rebuilding Hope) and that such dilution would burden his

as well as other psychiatric facilities in the area.


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Others opposed to the project include: Howard Babb, Jr., Public

Defender, Fifth Judicial Circuit (Marion, Lake, Hernando, Citrus and

Sumter Counties), Richard Shirley, Superintendent, Sumter County

School Board, Donna Gregory, RN, MS, Administrator, Lake County

Health Department, Florida Department of Health, Kenneth Mattison,

President/CEO, Florida Hospital-Waterman, Jim Judge, Executive

Director, Lake-Sumter Emergency Medical Services, Sue Cordova,

President/CEO, United Way of Lake and Sumter Counties, Inc., Debi

MacIntyre, M.Ed., Executive Director, Lake County Shared Services

Network, James Lowe, Executive Director, Lake County Action Agency,

Inc., Barbara Wheeler, Executive Director, Mid Florida Homeless

Coalition, Inc., Gerald Goldstein, Vice-President and CFO, Lake Centre

for Rehabilitation, Diane Pisczek, M.Ed., Executive Director, Lake Sumter

Children‟s Advocacy Center, Art Ayris, Executive Director, Christian Care

Center, Charles Mojock, Ed.D., President, Lake Sumter Community

College and Michael Sleaford, President and CEO, Reunion Bank of

Florida.

An opposition analysis letter was submitted by Lauren Borowsky,

Consultant, National Healthcare Associates, Inc. on behalf of The Vines

which stated:

• Due to an incorrectly applied occupancy rate, on July 23, 2010 the

Agency erroneously published need for seven new inpatient

psychiatric beds in District 3 when a net need of zero beds should

have been published.

• Agency rule criterion requires a minimum of total capacity of 40

inpatient psychiatric beds but the applicant has proposed a 30-bed

hospital.

• If approved, the project would result in a fifth freestanding inpatient

psychiatric hospital in District 3 and would be precluded from

participating in the Medicaid program. The applicant would therefore

compete with other nearby providers to garner admissions from the

same limited, non-Medicaid pool of patients.

• If approved, the project would in effect result in denied access to the

Medicaid population as Medicaid hospital covered services excludes

specialty psychiatric facilities with greater than 50 percent patients

with mental health diseases from participation.


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• Given natural barriers and geographic travel patterns throughout

north central Florida, incremental need in the area will be met by

existing providers.

• Lifestream Behavioral Center, the existing provider in Lake County,

also opposes the project.

• There is minimal outmigration of District 3 residents for psychiatric

treatment and is indicative of accessibility within the district.

• In-migration within District 3 is likely because of available beds.

• District 3 is a net in-migration district, meaning there is not an access

problem where residents must leave the area to obtain inpatient

psychiatric services and in fact, beds are sufficiently available for

persons to travel into District 3 for treatment.

• With the Lake County discharge use rate at 7.5 percent per 1,000

population (18 years of age and older for MDC 19 in Lake County) and

the state rate at 7.4 percent, the use rate is right on par with the state

rate, indicating no lack of available and accessible services.

• District 3 adult psychiatric hospital services are geographically

accessible to at least 90 percent of the district‟s adult population,

meeting the Agency‟s drive time accessibility criteria.

• The Vines noted several opposition letters state that this project would

be a duplication of services, and

• There is no evidence of not normal circumstances to warrant project

approval.

C. PROJECT SUMMARY

Haven Behavioral Services of Florida, LLC (CON #10094) proposes to

establish a 24-bed adult inpatient psychiatric hospital, at 55 Ponce de

Leon Avenue in Brooksville, in District 3, Hernando County, Florida. The

proposed location is at the former Brooksville Regional Hospital. Haven

indicates that the facility will do business as Haven Behavioral Hospital

of Brooksville and initiate service in June 2012. The applicant states the

service area for the proposed hospital will be Hernando, Citrus and

northern Pasco Counties.


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Haven Behavioral Services of Florida, LLC is a newly created, wholly-

owned subsidiary of Haven Behavioral Healthcare, Inc., a for-profit

corporation. Haven owns and operates nine psychiatric inpatient

facilities in six states, including two dedicated geriatric psychiatric

hospitals. The applicant indicates project application is based on “not

normal” circumstances, requesting approval to meet the need for

geriatric psychiatric services which the applicant states is not being met

by existing providers.

The proposed project involves a total cost of $1,913,485. The total

project cost includes: building, equipment, project development and

start-up costs. The project involves 14,544 gross square feet (GSF) of

renovation at a total construction cost of $946,534.


establish a 26-bed adult inpatient psychiatric hospital-in-a-hospital at

Leesburg Regional Medical Center-North, in Leesburg, Lake County.

Haven indicates that the facility will do business as Haven Behavioral

Hospital of Leesburg and initiate service in January 2012. The applicant

states the service area for the proposed hospital will be Lake and Sumter

Counties.

The proposed project involves a total cost of $1,881,983. The total

project cost includes: building, equipment, project development and

start-up costs. The applicant indicates that the project consists of

13,532 GSF of renovation at a total construction cost of $902,819.

The applicant proposes the following conditions for both CON #10094

and CON #10095:

1. Haven will provide services only to geriatric patients who require

inpatient treatment for a behavioral condition.

2. Due to the unique needs of the elderly, Haven will contract the

referral source for follow-up on patient discharges twice within the

first month after discharge to assist post hospitalization care givers

with maintaining the gains achieved during hospitalization.

3. Haven will employ a dedicated pharmacist on-site to assist in

medication management of geriatric psychiatric patients.


16

4. Haven will host separate annual mental health conferences for

health care professionals and the general community.

5. Haven will provide an annual report to the Agency summarizing

the MS-DRGs and psychiatric diagnoses of patients discharged

from the facility in the previous 12-month period.

6. Haven will create and maintain a report indicating dates of

discharge and follow up on patients post-discharge and submit the

report to the Agency annually.

7. Haven will certify to the Agency that there is an on-site, dedicated

pharmacist working at the proposed facility annually.

8. Haven will report the dates, locations, and titles of conferences

provided for health care professionals and community to the

Agency each year. The Agency will be notified of conferences in

advance of the meeting date and will be invited to attend.

The applicant’s proposed conditions (one through four) are as it stated.

Conditions five through eight were described as “monitoring conditions” by

the applicant. Should the 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.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review

criteria found in Section 408.035, Florida Statutes. 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 and data provided in the

application, and independent information gathered by the reviewer.

Applications are analyzed to identify strengths and weaknesses in each

proposal. If more than one application is submitted for the same type of

project in the same district (subdistrict), applications are comparatively

reviewed to determine which applicant best meets the review criteria.


17

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

amendments once an application has been deemed complete. The

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

As such, the applicant is responsible for the representations in the

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

Certification of the Applicant.

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

application in its entirety with consultation from the financial analyst,

Felton Bradley, who evaluated the financial data, and the architect, Scott

Waltz, who evaluated the architectural and the schematic drawings as

part of the application.

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicate the level of conformity of the proposed project with

the review criteria and application content requirements found in

Sections 408.035, and 408.037; applicable rules of the State of Florida,

Chapters 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? Or does the project proposed seek beds or services in excess of the fixed need pool? ss. 408.035 (1) (a), Florida Statutes, Rules 59C-1.008(2) and 59C-1.040(4) Florida Administrative Code.

In Volume 36, Number 29, dated July 23, 2010 of the Florida

Administrative Weekly, a fixed need pool of seven beds was published for

adult inpatient psychiatric beds in District 3 for the January 2016

planning horizon. This was based in part on the need projections

indicating District 3 occupancy was 75.44 percent whereas reported

occupancy was 74.46 percent2.

2 The July 2010 Bed Ned Projections & Service publication had incorrect 3rd quarter bed days for The Vines and did not include December 2009 patient days for The Centers, Inc., indicating 73.42 percent utilization when actual was 74.46 percent. Need projections had 75.44 percent due to formula error.


18

As of June 11, 2010, District 3 had 209 licensed adult inpatient

psychiatric beds and no CON approved adult psychiatric beds. District

3‟s licensed beds experienced an occupancy rate of 73.42 percent during

the 12-month period ending December 31, 2009. The applicant is

applying to establish new hospitals (CON #10094 with 24 beds and

CON #10095 with 26 beds) which exceed the seven beds in the fixed need

pool.

Of the six facilities in District 3 with licensed adult psychiatric beds as of

December 31, 2009, one is a general hospital (Class 1) and five are

freestanding (Class 3), as follows:

District 3 Adult Inpatient Psychiatric Utilization

Calendar Year 2009 Facility

County

Service Class

# Adult Beds

Adult Occupancy

Lifestream Behavioral Center Lake Class 3 39 68.67%

Shands at Vista Alachua Class 3 42 71.08%

Shands Hospital at the University of Florida Alachua Class 1 10 72.03%

Springbrook Hospital Hernando Class 3 61 93.45%

The Centers, Inc. Marion Class 3 15 75.56%

The Vines Marion Class 3 42 42.78%

District 3 Total 209 73.42% Source: Florida Hospital Bed Need Projections and Service Utilizations by District, July 2010 Batching Cycle. Need projections indicated occupancy was 75.44 percent therefore, need for seven beds was projected.

The following is a map of District 3‟s licensed adult inpatient psychiatric

facilities and the applicant‟s proposed Hernando County (CON

application #10094) and Lake County (CON application#10095) hospital

sites.


19

District 3 Adult Inpatient Psychiatric Facilities and Haven Behavioral Services of Florida, LLC

(CON #10094) Brooksville & (CON #10095) Leesburg

Source: Microsoft MapPoint 2006


20

The following table illustrates the driving distance in miles between the

existing facilities and the proposed Hernando County hospital site (CON application #10094):

Driving Distance in Miles – Existing Facilities and Proposed Site

Haven

Behavioral

Hospital of

Brooksville

(proposed

site)

The

Vines

The

Centers,

Inc.

Shands

at UF

Shands

at Vista

Lifestream

Behavioral

Center

Springbrook

Hospital

Haven Behavioral

Hospital of

Brooksville

(proposed site) 60.5 62.5 96.7 100.5 52.6 6.3

The Vines 60.5 5.9 38.8 42.4 37.3 66.2

The Centers, Inc. 62.5 5.9 42.4 46.0 39.0 67.9

Shands at UF 96.7 38.8 42.4 9.5 73.7 102.7

Shands at Vista 100.5 42.4 46.0 9.5 77.7 106.7

Lifestream

Behavioral Center 52.6 37.3 39.0 73.7 77.7 58.6

Springbrook

Hospital 6.3 66.2 67.9 102.7 106.7 58.6 Source: Mapquest

The following table illustrates the driving distance in miles between the

existing facilities and the proposed Lake County hospital site (CON application #10095):

Driving Distance in Miles – Existing Facilities and Proposed Site

Haven

Behavioral

Hospital of

Leesburg

(proposed

site)

The

Vines

The

Centers,

Inc.

Shands

at UF

Shands

at Vista

Lifestream

Behavioral

Center

Springbrook

Hospital

Haven Behavioral

Hospital of

Leesburg

(proposed site) 38.5 40.6 74.7 78.5 2.3 55.8

The Vines 38.5 5.9 38.8 42.4 37.3 66.2

The Centers, Inc. 40.6 5.9 42.4 46.0 39.0 67.9

Shands at UF 74.7 38.8 42.4 9.5 73.7 102.7

Shands at Vista 78.5 42.4 46.0 9.5 77.7 106.7

Lifestream

Behavioral Center 2.3 37.3 39.0 73.7 77.7 58.6

Springbrook

Hospital 55.8 66.2 67.9 102.7 106.7 58.6 Source: Mapquest

The chart below contains the population estimates for the total adult

population (age 18 and older) in District 3 by county for July 2009 and

the January 2016 planning horizon.


21

Population Estimates for District 3 (Population Age 18 and Over)

and Percent Change by County from July 2009 to the January 2016 Planning Horizon

Source: Agency for Health Care Administration Population Projections, published September 2009.

As shown above, District 3‟s population age 18 and over is expected to

experience 3.74 percent higher growth than the state.

Hernando County‟s population age 18 and over is anticipated to grow at

a 3.13 percent rate greater than the district and 6.87 percent greater

than the state. Hernando County is projected to account for 10.42

percent of the district‟s total July 2016 age 18 and over population. Lake

County‟s population age 18 and over is anticipated to grow at a 3.13

percent rate greater than the district overall and at a 6.87 percent

greater than the state overall. Lake County is projected to account for

18.75 percent of the district‟s total July 2016 age 18 and over

population.

b. “Not Normal” Circumstances.

Haven Behavioral Services of Florida, LLC (CON #10094) Brooksville

and (CON #10095) Leesburg: Haven states it is applying under “not

normal” circumstances for CON #10094 to establish a 24-bed adult

inpatient psychiatric hospital in District 3, in Hernando County and

CON #10095 to establish a 26-bed adult inpatient psychiatric hospital-

in-a-hospital at Leesburg Regional Medical Center North in Lake County.

County

Population Age 18 And Over July 2009

Population Age 18 And Over

January 2016

Percent Change

Alachua 206,512 220,926 6.98%

Bradford 23,229 24,698 6.32%

Citrus 121,761 134,758 10.67%

Columbia 51,907 56,757 9.34%

Dixie 12,753 14,088 10.47%

Gilchrist 13,711 15,329 11.80%

Hamilton 11,639 12,145 4.35%

Hernando 136,232 157,494 15.61%

Lafayette 7,448 8,495 14.06%

Lake 234,851 271,126 15.45%

Levy 31,963 35,960 12.51%

Marion 264,237 296,906 12.36%

Putnam 57,477 59,801 4.04%

Sumter 81,394 102,404 25.81%

Suwannee 33,161 39,487 17.46%

Union 12,911 13,710 6.19%

District Total 1,301,641 1,464,084 12.48%

State Total 14,668,626 15,949,963 8.74%


22

Both projects will have a dedicated geriatric focus, to provide care to an

underserved population. Haven states the need for geriatric psychiatric

services is not being met by existing providers in District 3. The

applicant states several “not normal” circumstances that justify the

projects. These areas are described below.

The Elderly in District 3 and the Service Area Receive Disproportionately

Less Inpatient Psychiatric Care than Other Adults and the Statewide

Rate

Haven states the elderly residents are underserved and do not receive the

same level of psychiatric care as other adults. The applicant states a

disproportionately lower use of inpatient services is received by the

elderly population. According to the applicant, in District 3 in 2009, the

elderly represented 15.2 percent of psychiatric discharges compared to

27.9 percent of the resident population and in the CON #10094 service

area the elderly received 16.9 percent of total psychiatric discharges but

were 34.2 percent of the population. In the CON #10095 service area in

2009 the elderly received 11.6 percent of total psychiatric discharges but

were 33.5 percent of the population. The applicant also states that

service area discharge use rates for elderly age 65-74 and elderly 75 and

over were “significantly less” than statewide rates for the same age

cohorts. Haven contends that the small proportion of elderly patients at

psychiatric facilities is more evidence that the elderly are underserved.

According to the applicant, statewide, 87 percent of adult psychiatric

patients were under the age of 65. In District 3, 85 percent of adult

psychiatric patients were under 65. Haven states in the absence of

dedicated geriatric psychiatric beds, the elderly are unlikely to receive

treatment even with exacerbation of an underlying behavioral condition.

Mental Health Conditions in Older Adults Not Addressed

Haven asserts one of the most important reasons that the elderly are less

likely to receive psychiatric care is that mental health conditions of older

adults are not addressed. The applicant explains that in normal aging,

important aspects of mental health include stable intellectual

functioning, capacity for change, and productive engagement with life.

However, a “substantial proportion” of the population 55 and older –

almost 20 percent-experience specific mental disorders that are not part

of normal aging. Older adults experience many of the same mental

disorders as other adults; however, the prevalence, nature, and course of

each disorder may be very different. Haven states that unaddressed in

older adults are depression, Alzheimer‟s disease, alcohol and drug

misuse and abuse, anxiety, late-life schizophrenia, and other conditions

that can be severely impairing or even fatal. The applicant concludes


23

that in general, assessment and diagnosis of mental disorders in older

adults can be challenging by virtue of several distinctive characteristics

which the project is designed to solve.

Service Area Nursing Home Residents Have Unaddressed Behavioral

Health Disorders

The applicant states that nursing homes have become the refuge of the

elderly with psychiatric conditions. For instance, the applicant states

depression prolongs nursing home care and increases costs in acute and

rehabilitative services while also increasing the risk of re-hospitalization

among elderly persons. According to the applicant, the 2004 National

Nursing Home Survey (NNHS) public use files indicated that 6.1 percent

of geriatric nursing home patients had a psychiatric principal diagnosis

and another 41.5 percent had a secondary psychiatric diagnosis.

Despite what the applicant considers a prevalence of psychiatric

conditions among nursing home residents, the applicant states the

mental health status of these patients may not be re-evaluated when a

major change in health status or exacerbation of a mental condition

occurs. In addition, even if a problem needing treatment is identified,

gaining placement in a specialized psychiatric facility can be challenging.

Haven states elderly mental health patients require specialized care, staff

training, and placement resources that are not generally available at

most behavioral health providers. The applicant identifies the following

as issues of elderly patients with regard to specialized care:

1. Incompatibility of elderly and non-elderly psychiatric patients

Adult patients under 65 are more likely to be hospitalized for

psychoses, usually schizophrenia and bipolar mood disorders,

than are geriatric patients, who are equally likely to be

diagnosed with degenerative nervous system disorders (such as

Parkinson‟s disease, Huntington‟s disease, or Alzheimer‟s

disease) or organic brain disturbances.

The psychotic non-elderly adult patient has few boundaries and

may display inappropriate behaviors. These patients may not

be able to tolerate the general intrusiveness of geriatric patients

with dementia, who are confused and may be frail.

Geriatric patients require different approaches to assessment,

diagnosis, and treatment modalities than non-elderly adults.


24

2. Medication Management

Another significant commitment required in providing care to

geriatric psychiatric patients is management of medications.

Geriatric patients typically take several prescriptions per day,

with an average of 9.5 prescriptions per patient in the NNHS.

This increases the probability of adverse drug effects and

suboptimal care.

The aging process leads to changes in the way medications are

tolerated. Geriatric psychiatric care includes evaluation and

effectiveness of the patient medications.

3. Specialized discharge planning and aftercare needs

Haven‟s specialized geriatric psychiatric care is focused on

coordination of care with nursing homes and assisted living

facilities and the patient‟s family. By specializing in only

geriatric care, Haven personnel are able to work closely with a

smaller number of providers.

4. Fall risk and patient safety

Patient falls are a much greater safety concern in the elderly

population. In the 2004 NNHS, residents with a principle or

secondary mental health diagnosis reported a significant

number of falls. Haven addresses the high potential risk of falls

in this population through a focus on assessment, staff

training, and development of protocols, physical plant design,

furniture, fixtures and safety devices.

5. Need to assist patients with Activities of Daily Living

Geriatric psychiatric patients in nursing homes routinely

require assistance with three or more limitations in activities of

daily living), including assistance with ambulation, toileting,

bathing, or feeding. When compared to the non-

institutionalized elderly, over 90 percent of who have no

limitations, geriatric patients require a staff who can provide

psychiatric care as well as nurses and certified nursing

assistants who are experienced in providing assistance in basic

skills, which more commonly are requirements for nursing

home or medical/surgical patients.


25

There Is An Insufficient Number of Dedicated Geriatric Psychiatric Beds

in the Service Area

Haven states there are an insufficient number of dedicated geriatric

psychiatric beds in the service area. In order to meet the needs of the

elderly mental health patients, the applicant believes providers need a

dedicated geriatric psychiatric facility or unit to provide separation of

elderly patients from other adults and furnishings, equipment, and

policies to prevent falls and minimize harm from unavoidable falls.

Specific to CON #10094, the applicant states the only dedicated geriatric

inpatient psychiatric beds in District 3 are at The Vines, which is 42

miles from Brooksville, and Springbrook Hospital (eight miles from

Brooksville per applicant‟s chart), which reported an occupancy rate

exceeding 93 percent. Specific to CON #10095, the applicant states The

Vines is 37 miles from Leesburg, and Springbrook Hospital, is 55 miles

from Leesburg. The applicant also stated that per callers to Lifestream

Behavioral Center, that facility‟s geriatric unit had been closed. Below is

a chart of the applicant‟s description of District 3 adult psychiatric

service providers and related data.

CON #10094 & CON #10095

District 3 Adult Psychiatric Service Providers

District

Country

CON #10094

Distance from

Haven Brooksville

(Miles)

CON #10095 Distance

from Haven

Leesburg(Miles)

2009 Utilization

Beds

2009 Utilization

Patient Days

2009 Utilization Occupancy

Rate

Dedicated Geriatric

Psych Unit or Program

Specialized Care Unit

Springbrook

Hospital

Hernando

8

55

61

10,897

93.4%

Program

Very high

occupancy;

older adult

program

Shands at UF Alachua 70 69 10 2,629 72.0% No

Shands at Vista Alachua 74 74 42 20,807 71.1% No

Lifestream

Behavioral

Center

Lake

35

2

39

9,405

68.7%

No

10-bed geriatric

unit closed

The Centers Marion 37 37 15 4,137 75.6% No

The Vines

Hospital

Marion

40

37

42

4,917

42.8%

Program

Source: CON applications #10094 & #10095, Table 2, page #19 stated to be from MapQuest.com.

The CON reviewer ran driving distances to the facilities using MapQuest

and we found the applicant‟s proposed Brooksville (CON #10094)

location was 6.3 miles from Springbrook Hospital. The applicant‟s

proposed Leesburg (CON #10095) is approximately 2.3 miles from

Lifestream Behavioral Center. However, many of the distances the

applicant proposes for the other facilities are closer than we found i.e.

the applicant indicates Shands at UF is approximately 70 miles from

both and we found it to be 96.7 miles from Brooksville and 74.7 from

Leesburg (see charts in Item E. 1.).


26

Focus on Serving the Geriatric Psychiatric Population

The applicant states that its parent, Haven Behavioral Healthcare, Inc.,

is an experienced provider of dedicated geriatric psychiatric services.

Haven has operated dedicated geriatric psychiatric facilities in Phoenix

(Arizona) and Denver (Colorado) with a majority of its patients being

between 70-89 years of age. The applicant states that as a geriatric

psychiatric provider, Haven understands and employs the resources to

provide psychiatric care that will make a difference in the community.

Over 55 percent of Haven‟s dedicated geriatric psychiatric patients are

referred from nursing homes and assisted living facilities, 30 percent

from patient families and doctors, with approximately 15 percent referred

from acute care providers (upon hospital discharge) and other sources.

The applicant states it has a proven track record of reaching out and

working with providers to identify elderly patients who can benefit from

geriatric psychiatric care. Haven‟s personnel work closely with area

nursing homes and assisted living facilities to assist in identifying

residents who meet admission criteria for inpatient psychiatric care.

By specializing in providing only geriatric psychiatric services (which

includes re-evaluating and optimizing medication regimens, specialized

small-group therapy sessions, and expertise in placement of elderly

patients in the most appropriate site of care) Haven states its personnel

are a valuable resource in helping health care providers to meet the

needs of geriatric patients.

Service Area Definition and Demand Projections

CON #10094 - Haven proposes to serve Hernando and Citrus Counties

in District 3 and northern Pasco County (District 5). The applicant

states that the total population in the service area is projected to grow by

41,844 total residents from 416,447 in 2010 to 458,291 in 2015 (by 10.0

percent). The elderly population, according to Haven, is projected to

grow at a faster rate from 117,674 in 2010 to 141,550 in 2015, gaining

23,876 persons (by 20.3 percent). Haven states that elderly percentage

of the total population in the service area is projected to increase from

28.3 percent in 2010 to 30.9 in 2015.


27

Estimated and Projected Population District 3, Service Area, and Hernando, Citrus and Northern Pasco Counties

District 3

2010

2015

Change 2010-2015

Total Population 1,622,636 1,764,210 141,574

Under 65 1,255,154 1,329,843, 74,689

65 and Over 367,482 434,367 66,885

Percent of Population 65 and Over 22.6% 24.6%

Total Service Area

Total Population 416,447 458,291 41,844

Under 65 298,773 316,741 17,968

65 and Over 117,674 141,550 23,876


Hernando County


Under 65 120,891 129,863 8,972

65 and Over 50,139 58,761 8,622


Citrus County


Under 65 97,017 97,711 694

65 and Over 47,590 58,761 11,171


Pasco County


Under 65 80,865 89,167 8,302

65 and Over 19,945 24,028 4,083


Source: CON application #10094, Table 4, page #25.

The applicant indicates on CON application #10094, page #25, that the

Pasco County service area zip codes are: 33523, 33525, 34620, 34667,

and 34669. The CON reviewer confirmed that all of these with the

exception of zip code 34620, which is not found in United States Postal

Service database, are assigned to cities in Pasco County.3

CON #10095 - Haven proposes that its service area will be Lake and

Sumter Counties. The applicant states that the total population in the

service area is projected to grow by 51,951 total residents over the next

five years, from 390,597 in 2010 to 442,548 in 2015 (by 13.3 percent).

The elderly population, according to Haven, is projected to grow at a

faster rate from 108,135 in 2010 to 132,021 in 2015, gaining 23,886

persons (by 23.1 percent). Haven states that elderly percentage of the

service area‟s total population is projected to increase from 27.7 percent

in 2010 to 29.8 in 2015.

3 USPS website at http://zip4.usps.com/zip4/zcl_3_results.jsp

http://zip4.usps.com/zip4/zcl_3_results.jsp


28

CON #10095 Estimated and Projected Population

District 3, Service Area, Lake and Sumter Counties District 3

2010

2015

Change 2010-2015

Total Population 1,622,636 1,764,210 141,574

Under 65 1,255,154 1,329,843, 74,689

65 and Over 367,482 434,367 66,885


Total Service Area


Under 65 285,068 317,008 31,940

65 and Over 108,135 132,021 23,886


Lake County


Under 65 217,563 237,889 20,326

65 and Over 76,694 92,465 15,771


Sumter County


Under 65 67,505 79,119 11,614

65 and Over 31,441 39,556 8,115


Source: CON application #10095, Table 4, page #25.

The following applies to CON #10094 and #10095.

Haven states the need for the proposed program is demonstrated by

(1) the underutilization of geriatric psychiatry inpatient care among the

elderly population as evidenced through a comparison of existing

utilization in the service area to the expected utilization based on

national geriatric inpatient psychiatry admission experience and by

(2) the unmet need for increased access to dedicated geriatric psychiatric

care for underserved populations in nursing homes and assisted living

facilities. The applicant states that unmet need is evidenced by the low

use rate in the service area and the unmet need/access issues associated

with residents in nursing homes and assisted living facilities who need

geriatric psychiatric services provided in a programmatic structure and

supportive environment that will meet their specific psychiatric needs.

Haven contends this need is not and cannot be readily met in a facility

that does not have a separate and distinct geriatric program and

environment.


29

CON #10094 Historical versus Expected Geriatric Psychiatric Discharges

2009 Service Area and Florida Experience and National IPF (Inpatient Facility) Experience

2009 Elderly

Population

IPF Use

rate/1,000

Expected

Discharges

Resident

Discharges

Variance

IPF Beds

Needed

Hernando 48,641 5.33 259 215 (44) 2

Citrus 47,062 5.33 251 98 (153) 8

Pasco (Partial) 19,188 5.33 102 105 3 (0)

Total 114,891 5.33 612 418 (194) 10

Florida 3,302,610 5.33 17,594 13,603 (3,991) 205 Source: CON application #10094, Table 6, page #27.

The applicant states that the estimated need is for 10 inpatient facility

beds.

CON #10095 Historical versus Expected Geriatric Psychiatric Discharges

2009 Service Area and Florida Experience and National IPF (Inpatient Facility) Experience

2009 Elderly

Population

IPF Use

rate/1,000

Expected

Discharges

Resident

Discharges

Variance

IPF Beds

Needed

Lake 75,582 5.33 403 307 (96) 4

Sumter 30,238 5.33 161 81 (80) 4

Total 105,820 5.33 564 388 (176) 9


The applicant states that the estimated need is for nine inpatient facility

beds. It is noted that the applicant‟s table adds up to a need for eight.

Both CON #10094 & CON #10095: The applicant contends that the

estimated need for inpatient facility beds in the service areas and 205

inpatient facility beds statewide is conservative, as it:

• does not include the population 55 to 64 that could be served in a

geriatric psychiatry program (65 percent of Medicare inpatient facility

patients are classified as disabled and are under age 65);

• does not include the unmet need that would be generated by nursing

home and assisted living residents that is not currently being served

nationally by geriatric psychiatry programs, and

• does not include the demand generated by seasonal residents.

Haven asserts that the bed need of 10 for CON #10094 Brooksville and

nine for CON #10095 Leesburg only represents the number of inpatient

beds that are currently needed if the service area residents received

inpatient psychiatric care at the same rate as on average the elderly


30

receive inpatient psychiatric care on a national level. However, despite

these limitations, the applicant states a comparison to the national

inpatient facility rate for the elderly does provide evidence that the

geriatric populations with inpatient psychiatric needs are underserved in

both the service areas and the state.

With the growing elderly population, the applicant states that applying

this approach to the 2013 population in the service area (year two of

proposed project) will result in an even higher unmet need for geriatric

psychiatry beds in both the service area and the state.

CON #10094 - The applicant estimates an inpatient facility bed need of

14 by 2013.

CON #10094

Projected Unmet Need for Geriatric Psychiatric Discharges Using National IPF (Inpatient Facility) Experience

2013 Service Area and State of Florida 2013

Elderly Population

IPF Use

rate/1,000

Expected

Discharges

2009 Resident

Discharges

Variance

2013 IPF Beds Needed

Hernando 54,853 5.33 292 215 (77) 4

Citrus 51,375 5.33 274 98 (176) 9

N. Pasco 22,303 5.33 119 105 (14) 1

Total 128,531 5.33 685 418 (267) 14


CON #10095 – The applicant estimates an inpatient facility bed need of

11 by 2013.

CON #10095

Projected Unmet Need for Geriatric Psychiatric Discharges Using National IPF (Inpatient Facility) Experience

2013 Service Area and State of Florida 2013

Elderly Population

IPF Use

rate/1,000

Expected

Discharges

2009 Resident

Discharges

Variance

2013 IPF Beds Needed

Lake 85,176 5.33 454 370 (84) 4

Sumter 35,892 5.33 191 62 (129) 7

Total 121,068 5.33 645 432 (213) 11


Both: Haven states that the increased utilization associated with unmet

need from nursing homes and assisted living facilities (ALFs) was

developed in part based on its experience in working closely with nursing

homes to provide the geriatric psychiatry inpatient needs of their

residents. Nursing home and ALF patients have historically represented


31

55 percent of Haven‟s admissions. The applicant states implementing a

similar program in the service area and working closely with the area

nursing homes would result in a similar distribution of geriatric patients

in the proposed facility.

Specific to CON #10094 - Haven states that discharges to nursing homes

and ALFs as a result of its entry into the service area are projected to

increase by 425 discharges between 2009 and 2013. At 80 percent

occupancy, the applicant states that increase would result in a need for

22 additional beds associated with serving the unmet need among

nursing home and ALF residents.

Specific to CON #10095 - Haven states that discharges to nursing homes

and ALFs as a result of its entry into the service area are projected to

increase by 308 discharges between 2009 and 2013. At 80 percent

occupancy, the applicant states that increase would result in a need for

16 additional beds associated with serving the unmet need among

nursing home and ALF residents.

Applies to both CON #10094 and CON #10095 - However, it is unclear

how the applicant‟s practice of discharging more of its patients than

other psychiatric hospitals to nursing homes and ALFs would result in

more admissions to its facility.

Specific to CON #10094 - The applicant states that as the only provider

of geriatric psychiatric inpatient care in the service area it projects to

provide 4,800 patient days of care in year one and 7,410 days in year

two. The applicant projects occupancy in year two to be 84.6 percent.

Haven anticipates 320 total discharges in year one with an average

length of stay to be 15 days, and an average daily census of 13.2 in its

24-bed unit at 54.8 percent occupancy. In year two Haven projects 494

total discharges with an average length of stay 15 days, and an average

daily census 20.3 in the 24-bed unit at 84.6 percent occupancy. The

CON reviewer data run indicates that the ALOS for CON #10094 service

area residents age 55 years and over who received inpatient psychiatric

care during CY 2009, was 8.91 days. The service area patient age 65

and over ALOS is 8.76 days.

Specific to CON #10095 - The applicant states that as the only provider

of geriatric psychiatric inpatient care in the service area it projects to

provide 4,515 patient days of care in year one and 7,855 days in year

two. The applicant projects occupancy in year two to be 82.8 percent.


32

Haven anticipates 301 total discharges in year one with an average

length of stay to be 15 days, and an average daily census of 12.4 in its

26-bed unit at 47.6 percent occupancy. In year two Haven projects 524

total discharges with an average length of stay 15 days, and an average

daily census 21.5 in the 26-bed unit at 82.8 percent occupancy.

CON #10095 service area residents age 55 years and over who received

inpatient psychiatric care during CY 2009, had an ALOS of 6.58 days.

The age 65 and over ALOS is 6.31 days.

Applies to Both CON #10094 & CON #10095 – The applicant does not

document that patients in need of inpatient psychiatric services are not

able to access these services. Haven does not address the two providers

that report to have geriatric programs or units. It not clear how Haven‟s

historical discharges to nursing homes and ALFs can be used to show

increased admissions. The applicant‟s projected ALOS exceeds the

service area residents age 55 and over, the state and national average.

Specific to CON #10094 - The table below shows Calendar Year 2009

service area psychiatric resident (DRGs 880-887) discharges for patients

aged 55 and over and those aged 65 and over. The applicant indicates

that the service area included Citrus and Hernando Counties and the five

zip codes in Pinellas County. The reviewer was able to confirm four zip

codes were correct and one zip is not operational (see note in chart

below). The individual facility‟s total discharges include all discharges

reported by the facility.


33

CON Application #10094 Psychiatric Patient Discharges (DRGs 880-887)

Citrus, Hernando and partial* Pasco County Residents Age 55 & Over and Age 65 & Over CY 2009

Facility & County

Citrus, Hernando and partial* Pasco County

Resident Discharges

Total Facility

Discharges

Discharges as Percent of the Facility Total

Age 55 & Over

Age 65 & Over

Age 55 & Over

Age 65 & Over

Lifestream Behavioral Center/Lake 1 0 2,296 0.04% 0.00%

Shands at Vista/Alachua 16 5 2,667 0.60% 0.19%

Shands Hospital at the University of Florida/Alachua 3 1 33,933 0.01% 0.00%

Springbrook Hospital/Hernando 320 202 2,084 15.36% 9.69%

The Centers, Inc./Marion 0 0 952 0.00% 0.00%

The Vines/Marion 24 11 1,110 2.16% 0.99%

District 3 Acute Care Hospitals/Multiple Counties 82 63

Non-District 3 Hospitals/Multiple Counties 223 125

Service Area Resident Discharge Total 669 407 Source: Florida Center for Health Information and Policy Analysis database run date of December 1, 2010 (age 65 or older) and December 7, 2010 (age 55 or older).

*Note: CON application #10094, page #25, indicates that the Pasco County service area zip codes are: 33523,

33525, 34620, 34667, and 34669. The CON reviewer confirmed all except 34620 are in Pasco County. Zip code 34620 was not found in the USPS database.

As shown above, Springbrook Hospital is the facility most impacted by

the project.

Specific to CON #10095 Leesburg - The table below shows Calendar Year

2009 service area psychiatric resident (DRGs 880-887) discharges for

patients aged 55 and over and those aged 65 and over. The individual

facility‟s total discharges include all discharges reported by the facility.


34

CON Application #10095 Psychiatric Patient Discharges (DRGs 880-887)

Lake and Sumter County Residents Age 55 & Over and Age 65 & Over CY 2009

Facility & County

Lake and Sumter County Resident

Discharges

Total Facility

Discharges

Discharges as Percent of the Facility Total

Age 55 & Over

Age 65 & Over

Age 55 & Over

Age 65 & Over

Lifestream Behavioral Center/Lake 361 178 2,296 15.72% 7.75%

Shands at Vista/Alachua 15 9 2,667 0.56% 0.34%

Shands Hospital at the University of Florida/Alachua 19 15 33,933 0.06% 0.04%

Springbrook Hospital/Hernando 32 22 2,084 1.56% 1.06%

The Centers, Inc./Marion 0 0 952 0.00% 0.00%

The Vines/Marion 20 10 1,110 1.80% 0.90%

District 3 Acute Care Hospitals/Multiple Counties 113 93

Non-District 3 Hospitals/Multiple Counties 87 49

Service Area Resident Discharge Total 647 376 Source: Florida Center for Health Information and Policy Analysis database run date of December 1, 2010 (age 65 or older) and December 7, 2010 (age 55 or older).

As shown above, Lifestream Behavioral Center is the facility most

impacted by the project.

2. Agency Rule Criteria/Preferences a. Chapter 59C-1.040, Florida Administrative Code, contain factors to

be considered in the review of Certificate of Need Applications for hospital inpatient general psychiatric services for adults.

1. Rule 59C-1.040(4)(e) 1, Florida Administrative Code:

Applicants shall provide evidence in their applications that their proposal is consistent with the needs of the community and other criteria contained in Local Health Council Plans, the district Alcohol, Drug Abuse and Mental Health Plan, and the State Health Plan.

Both CON #10094 and #10095: The applicant discusses mental

health issues in the elderly population cited in a report titled

“Aging and Mental Health in Florida”.4 Although Florida no longer

has a State Health Plan, and preference criteria for CON review is

no longer required of Local Health Council Plans, the appropriate

plan for mental health services in Hernando and Lake Counties is

4 The applicant includes this in CON application #10103, Attachment O.


35

maintained by the Department of Children and Families. The

Department monitors compliance with this plan through an

annual survey of facilities within both counties.

2. Rule 59C-1.040(4)(e) 3, Florida Administrative Code: In order

to ensure access to hospital inpatient general psychiatric services for Medicaid-eligible and charity care adults, 40 percent of the gross bed need allocated to each district for hospital inpatient general psychiatric services for adults should be allocated to general hospitals.

District 3 has 209 licensed inpatient adult psychiatric beds (see

Item 1 a). Ten of these are at Shands at the University of Florida, a

general hospital (Class 1) and 199 are in five freestanding (Class 3)

hospitals.

This represents a 4.78 percent (10/209) allocation to general

hospitals.

Accordingly, this criterion will not be met with the approval of

either project (CON #10094 and CON #10095). Regardless,

previous changes in Medicaid reimbursement indicate that an

increasing percentage of reimbursement for Medicaid patients in

this area will be by HMO managed care providers.

3. Rule 59C-1.040(4)(e) 4, Florida Administrative Code:

Regardless of whether bed need is shown under the need formula, no additional hospital inpatient general psychiatric beds for adults shall normally be approved in a district unless the average annual occupancy rate of the licensed hospital inpatient general psychiatric beds for adults in the district equals or exceeds 75 percent for the 12-month period ending six months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

The Agency‟s utilization publication (page 113) indicated that adult

psychiatric beds in the district experienced 73.42 percent

occupancy for the January 2009 through December 2009 reporting

period. Actual utilization was 74.46 percent but the Agency‟s need

projections (page 31) erroneously indicated 75.44 percent.

Regardless, the applicant‟s projects (CON #10094 and

CON #10095) involve beds in excess of the projected seven-bed

need.


36

b. Priority Considerations for hospital inpatient general psychiatric

services (Rule 59C-1.040 (4) (i), Florida Administrative Code) (NOTE: All references to child/adolescent psychiatric services are deleted). In weighing and balancing statutory and rule review criteria, preference will be given to both competing and non-competing applicants who:

1. Provide Medicaid and charity care days as a percentage of their total patient days of total patient days provided by other hospitals in the district, as determined for the most recent calendar year prior to the year of the application for which data are available from the Health Care Board.

The table below shows existing adult psychiatric providers‟ amount

of combined CY 2009 charity care and Medicaid.

District 3 Adult Inpatient Psychiatric Facilities Percentage of Combined Medicaid and Charity Care

For FY 2009 Facility

Combined Medicaid/Charity

Lifestream Behavioral Center 16.38%

Shands at Vista N/A

Shands Hospital at the University of Florida 31.49%

Springbrook Hospital 0.48%

The Centers, Inc. 9.27%

The Vines 5.03% Source: 2009 Agency for Health Care Administration Hospital Financial Data. Note: Shands Hospital at UF files consolidated financial report which includes Shands at Vista financial data.

Haven Brooksville (CON #10094) and Haven Leesburg (CON

#10095): As freestanding psychiatric hospitals, the applicant‟s

proposed hospitals may not receive Medicaid fee for service

reimbursement. It is anticipated that with changes in Medicaid

reimbursement, an increasing percentage of reimbursement for

Medicaid patients will be by HMO managed care providers.

Haven states that both facilities will provide zero

Medicaid/Medicaid HMO days and charity care will be 1.5 percent

of each facility‟s total patient days. The applicant does not

condition CON #10094 and CON #10095 to any charity or indigent

care percent.


37

2. Propose to serve the most seriously mentally ill patients to

the extent that these patients can benefit from a hospital-based organized inpatient treatment program.

Both CON application #10094 and CON application #10095

indicate the applicant, Haven Behavioral Services of Florida, LLC,

will serve the most seriously mentally ill geriatric patients to the

extent that these patients can benefit from a hospital-based

organized geriatric inpatient treatment program. The applicant

states that its commitment is evidenced in its admissions criteria,

severity of illness criteria, and program limitations (exclusionary

criteria).

3. Propose to serve Medicaid-eligible persons.


indicate the applicant, Haven Behavioral Services of Florida, LLC

will provide services to all patients who meet admission criteria,

regardless of payer class. However, the applicant does not propose

to condition the project to a measurable provision of care to

Medicaid patients.

4. Propose to serve individuals without regard to their ability to

pay.



will provide services to all patients who meet admission criteria,

regardless of ability to pay. However, the applicant does not

propose to condition the project to a measurable provision of care

to charity care patients.

5. Agree to be a designated public or private receiving facility.



will not seek Baker Act receiving facility designation for either

proposed facility.


38

b. Minimum Size of Specialty Hospitals (Rule 59C-1.040(3)(e) Florida

Administrative Code). A specialty hospital providing hospital inpatient general psychiatric services shall have a minimum total capacity of 40 beds. The minimum capacity of a specialty hospital providing hospital inpatient general psychiatric services may include beds used for hospital inpatient substance abuse services regulated under Rule 59C-1.041, Florida Administrative Code. The separately organized units for hospital inpatient general psychiatric services for adults in specialty hospitals shall have a minimum of 15 beds (Rule 59C-1.040(5), Florida Administrative Code).

The applicant, Haven Behavioral Services of Florida, LLC, proposes a 24-

bed adult inpatient psychiatric facility in CON application #10094 and

26-bed adult inpatient psychiatric facility in CON application #10095.

The applicant‟s projects do not meet this criterion.

c. Access Standard. Hospital inpatient general psychiatric services should be available within a maximum ground travel time of 45 minutes under average travel conditions for at least 90 percent of the district's total population (Rule 59C-1.040(6), Florida Administrative Code).

Both: Haven Brooksville (CON #10094) & Haven Leesburg

(CON #10095): The applicant states that there are inpatient adult

psychiatric services within 45 minutes for at least 90 percent of the

district‟s total population. However, the applicant indicates mixed adult

psychiatric services are not optimal for elderly patients. Further, specific

to CON #10094, the applicant states the only dedicated geriatric

inpatient psychiatric beds in District 3 are at The Vines in Ocala, which

is 40 miles from Brooksville, and Springbrook Hospital (eight miles from

Brooksville), which reported at 93.4 percent occupancy rate in 2009.

Specific to CON #10095, the Vines in Ocala, is 37 miles from Leesburg,

and Springbrook Hospital, is 55 miles from Leesburg. The applicant also

stated that, per calls to Lifestream Behavioral Center, that facility‟s

geriatric unit had been closed.

It is noted that the Agency considers adult psychiatric patients to be

patients 18 years of age and older. For CON purposes, there is no

Agency recognized geriatric designation for adult psychiatric patients.


39

d. Quality of Care.

1. Compliance with Agency Standards. Hospital inpatient

general psychiatric services for adults shall comply with the Agency standards for program licensure. Applicants who include a statement in their certificate of need application that they will meet applicable Agency licensure standards are deemed to be in compliance with this provision (Rule 59C-1.040(7)(a), Florida Administrative Code).



will meet all of the applicable agency licensure standards.

2. Continuity. Providers of hospital inpatient general psychiatric

services shall also provide outpatient services, either directly or through written agreements with community outpatient mental health programs, such as local psychiatrists, local psychologists, community mental health programs, or other local mental health outpatient programs (Rule 59C-1.040(7)(d), Florida Administrative Code).



will work closely with community mental health resources to

assure that its patients have access to the full continuum of

mental health services needed to support their requirements.

Further, the applicant states it will work closely with nursing

homes and assisted living facilities to identify residents who meet

admission criteria for inpatient geriatric psychiatric or other site of

care. Haven does not propose to provide outpatient services.

3. Screening Program. All facilities providing hospital inpatient

general psychiatric services shall have a screening program to assess the most appropriate treatment for the patient. Patients with a dual diagnosis of a psychiatric disorder shall be evaluated to determine the types of treatment needed, the appropriate treatment setting, and, if necessary, the appropriate sequence of treatment for the psychiatric and substance abuse disorders (Rule 59C-1.040(7)(e), Florida Administrative Code).



will make sure all referrals undergo a detailed screening prior to


40

admission. Initial screening is the process of determining the

treatment needs of a patient and coordinating a referral within

Haven Behavioral or alternate provider. An inquiry call form is

completed on every call. The applicant states that persons who are

not appropriate for admission at Haven will be referred to the

appropriate level of care. Callers who present with an emergency

situation will be advised to call 911. Haven states that emergency

assessments will be available 24 hours a day, seven days a week.

e. Services Description (Rule 59C-1.040(8), Florida Administrative

Code). An applicant for hospital inpatient general psychiatric services shall provide a detailed program description in its certificate of need application including: 1. Age groups to be served.



will offer geriatric psychiatric programs designed to meet the

psychiatric needs of the elderly and will admit patients 55 years of

age and older.

It is noted that the Agency considers adult psychiatric patients to

be patients 18 years of age and older. For CON purposes, there is

no Agency recognized geriatric designation for adult psychiatric

patients.

2. Specialty programs to be provided.



will offer geriatric psychiatric services designed to meet the

psychiatric needs of the elderly experiencing behavioral health

disorders by providing inpatient behavioral evaluation, treatment,

and stabilization. Haven states its philosophy is one of working

together with family, physicians, long-term care providers, and

other agencies involved in healthcare to meet the needs of the

elderly.


41

3. Proposed staffing, including the qualifications of the clinical

director and a description of staffing appropriate for any specialty program. Haven Brooksville (CON #10094) and Haven Leesburg (CON #10095):

Position

FTEs Year One Ending May 2012

FTEs Year Two Ending May 2013

Administrator 1.00 1.00

Director of Nursing 1.00 1.00

Admissions Director 1.00 1.00

Secretary 1.00 1.00

Medical Records Clerk 1.00 1.00

Director of Business Development 1.00 1.00

Unit/Program Director 1.00 1.00

Psychiatrist 1.00 1.00

RN‟s 8.00 8.00

Mental health Techs 7.00 7.00

Psychologist 1.00 1.00

Social Service Director 1.00 1.00

Activity Director 1.00 1.00

Activities Assistant 1.00 1.00

Social Service Assistant 1.00 1.00

Total FTEs* 28.00 28.00 Source: CON application #10094, Schedule 6 and CON application #10095, Schedule 6. *The Agency notes no pharmacist FTEs. A dedicated pharmacist was discussed by the applicant at the public hearing on the CON application #10095 project. Opposition at the public hearing indicated the applicant does not include a pharmacist in Schedule 6. This is confirmed by the Agency.

4. Patient groups by primary diagnosis ICD-9 code that will be

excluded from treatment.

CON #10094 and CON #10095 - Haven lists the following as

conditions that exclude individuals from treatment:

Persons who would not benefit from a program designed for the

geriatric population.

A patient with a history of violent behavior beyond the

capabilities of the staff and physical environment to contain and

safely manage the patient with the current patient population.

Medically unstable and/or requiring acute medical hospital

level of care, for example: uncontrolled insulin-dependent

diabetes mellitus, changes in level of consciousness, acute

abdominal pain, severe lacerations or trauma/significant

bleeding, patients requiring isolation, non-healing wounds, total

immobility, continuous intravenous fluids, or sudden onset

severe psychosis/delusions/delirium (prior to medical

clearance).


42

5. Therapeutic approaches to be used.

Both CON #10094 and CON #10095 indicate Haven Behavioral

Services of Florida, LLC will utilize a combination of medication,

psychotherapy and other geriatric specific treatment interventions.

Treatment plans are individualized based on the comprehensive

assessments and the identified needs. Treatment for geriatric

psychiatric patients at Haven Behavioral Services includes:

Comprehensive initial and ongoing assessments by the

psychiatrist, medical practitioner and clinical staff at admission

and throughout the hospital stay.

Medication prescribed by the psychiatrist or other physician

with onsite pharmacy services.

Group therapies, including reminiscence, coping with loss,

signs and symptoms of treatment issues, self-esteem, medical

education and compliance, life skills, cognition enhancement,

and dexterity and movement activities.

Activities therapy: improve reality testing, maximize

independent performance in self-care skills, experience

constructive outlets for hostile, aggressive feelings, tension and

anxiety, develop improved physical fitness, sensory perception,

and motor skills coordination, and improved cognitive task

skills.

Individual therapy will be provided by therapy staff and/or

psychiatrist and is individualized for each patient‟s needs.

Family therapy will be provided by therapy staff or the

psychiatrist as needed to provide education and support to the

family on the aging process and behaviors/symptoms

associated with the patient‟s diagnosis.

The applicant states it will also provide discharge planning which

will be developed in collaboration with the patient, family,

treatment team, referring agency, and agencies/facilities the

patient will be referred to upon discharge and referral services.


43

6. Expected sources of patient referrals.


indicate Haven Behavioral Services of Florida, LLC anticipates

referrals for its respective geriatric psychiatric programs to come

from nursing homes, assisted living facilities, patient families,

doctors, acute care facilities, emergency room, long-term acute

care hospitals, home health agencies and secured Alzheimer‟s

facilities.

7. Expected average length of stay for the hospital inpatient

general psychiatric services discharges by age group.



expects, based on the historical experience of its parent company,

an average length of stay of 15 days. CON #10094 service area

residents age 55 and over had an 8.91 ALOS in CY 2009. CON

#10095 service area residents age 55 and over had a 6.58 ALOS in

CY 2009. The applicant‟s ALOS exceeds the service areas and

national ALOS.

8. Projected number of hospital inpatient general psychiatric

services patient days by payer type, including Medicare, Medicaid, Baker Act, private insurance, self-pay and charity care patient days for the first two years of operation after completion of the proposed project.

The applicant states that as a geriatric psychiatric provider, almost

all patient days are projected to be provided to Medicare and

Medicare HMO patients. The applicant‟s projections for each

project are in the tables below.

Haven Brooksville (CON #10094)

Payer Mix Payer Year One Year Two

Medicare 76.8% 83.8%

Medicare HMO 4.5% 6.0%

Commercial 5.0% 5.0%

Self-Pay/Charity 13.7% 5.2%

Total 100.0% 100.0% Source: CON application #10094, Table 14, page #54.


44

Haven Leesburg (CON #10095) Payer Mix

Payer Year One Year Two

Medicare 71.9% 79.5%

Medicare HMO 8.9% 10.0%

Commercial 5.0% 5.0%

Self-Pay/Charity 14.2% 5.5%

Total 100.0% 100.0% Source: CON application #10095, Table 14, page #54.

9. Admission policies of the facility with regard to charity care

patients.

Both: Haven Behavioral Services of Florida, LLC will provide

geriatric services to all patients regardless of payer source. Haven

states its admissions policy for charity care patients requires each

patient to complete a financial assistance application which is

designed to collect the income level and related documentation in

accordance with applicable state law. Persons eligible for Medicaid

who receive services not covered by Medicaid are considered to be

financially indigent. Haven defines a medically indigent person as

a person whose personal liability for medical or facility bills after

payment by third-party payers exceeds 40 percent of the person‟s

annual gross income and cash assets.

A determination of the patient‟s ability to pay the remainder of the

bill will be based on whether the patient can be reasonably

expected to pay the accounts in full over a two-year period. The

applicant lists the following as factors considered in determining

the eligibility for charity care:

Gross income

Family size

Employment status and future earning capacity

Other financial assets and resources

Other financial obligations

Amount and frequency of facility/medical bills


45

f. Quarterly Reports (Rule 59C-1.040(10), Florida Administrative

Code). Facilities providing licensed hospital inpatient general psychiatric services shall report to the agency or its designee, within 45 days after the end of each calendar quarter, the number of hospital inpatient general psychiatric services admissions and patient days by age and primary diagnosis ICD 9 code.

Both CON application #10094 and CON application #10095 indicate

Haven Behavioral Services of Florida, LLC will report to the Agency or its

designee, within 45 days after the end of each calendar quarter, the

number of hospital inpatient general psychiatric services admissions and

patient days by age and primary diagnosis ICD-9 code.

4. 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.




planning horizon. District 3 has 209 licensed inpatient adult psychiatric

beds.

As previously stated, District 3 experienced an occupancy rate of 73.42

percent during the 12-month period ending December 31, 2009. As of

September 2, 2010, four adult inpatient psychiatric beds are proposed to

be delicensed at the Vines.

Haven Brooksville (CON #10094) and Haven Leesburg (CON #10095):

The applicant states the only dedicated geriatric inpatient psychiatric

beds in District 3 are at The Vines in Ocala, which is 40 miles from

Brooksville (CON #10094), and Springbrook Hospital (eight miles from

Brooksville), which reported at 93.4 percent occupancy rate in 2009.

Specific to CON #10095 - The Vines is 37 miles from Leesburg, and

Springbrook Hospital is 55 miles from Leesburg. The applicant also

stated that per calls to Lifestream Behavioral Center, that facility‟s

geriatric unit had been closed. Also, the applicant provides excerpts

from its letters of support as evidence of need.


46

It is noted that the Agency considers adult psychiatric patients to be

patients 18 years of age and older. For CON purposes, there is no

Agency recognized geriatric designation for adult psychiatric patients.

See Item E.1. for additional on the applicant‟s need discussion.

b. Does the applicant have a history of providing quality of care and

has the applicant demonstrated the ability of providing quality care? ss. 408.035(1)(c), Florida Statutes.

Applies to CON #10094 and #10095 - Haven Behavioral Services of

Florida, is a newly created, wholly-owned subsidiaries of Haven

Behavioral Healthcare, Inc., ultimately parented by Haven Behavioral

Healthcare Holdings, LLC. These entities do not currently provide

services in the State of Florida. Haven states it has a history of providing

quality care and has received the gold seal of approval from The Joint

Commission in six of its hospitals. The applicant states it has an

extensive performance improvement plan that will be implemented.

Haven provides its scope of quality and performance improvement

activities for its North Denver facility, and its performance improvement

plan in the application‟s attachment Q.

Haven provides a brief description of its ability to provide quality care

and indicates that it will apply for Joint Commission accreditation within

one year of beginning operations.

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.

Haven Brooksville (CON #10094): The financial impact of the project

will include the project cost of $1,913,485 and year two operating costs

of $5,041,769.

Haven Leesburg (CON #10095): The financial impact of the project will

include the project cost of $1,881,983 and year two operating costs of

$5,218,930.

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.


47

The applicant is a development stage corporation established in 2010 to

acquire and operate behavioral healthcare facilities. According to the

audit, the applicant has $240,000 in total assets and $40,000 in

intercompany payables and with no operations.

The applicant is a wholly-owned subsidiary of Haven Behavioral Services,

LLC, which is wholly-owned by Haven Behavioral Healthcare, Inc., which

is wholly-owned by Haven Behavioral Healthcare Holdings, LLC (ultimate

parent, or parent).

The applicant provided audited financial statements of its ultimate

parent company, Haven Behavioral Healthcare Holdings, LLC, a for-profit

corporation, for the periods ending December 31, 2009 and 2008. These

statements were analyzed for the purpose of evaluating the parent‟s

ability to provide the capital and operational funding necessary to

implement the project.

Short-Term Position:

The parent‟s current ratio of 2.2 is slightly above average and indicates

current assets are over two times current liabilities, a good position. The

working capital (current assets less current liabilities) of $18.4 million is

a measure of excess liquidity that could be used to fund capital projects.

The ratio of cash flow to current liabilities of 0.4 is below average and a

weak position. Overall, the parent has an adequate short-term position.

(See table below).

Long-Term Position:

The ratio of long-term debt to net assets of 0.7 percent is above average

and indicates that the parent may have difficulty obtaining future debt

financing if necessary. The ratio of cash flow to assets of 3.7 percent is

well below average and a weak position. The most recent year had

revenues in excess of expenses of $131,925, which resulted in a 0.1

percent operating margin (roughly break even). Taking into account non-

operating costs of $4,681,071, the parent had a loss before income taxes

of $4,549,146. Overall, the parent has a moderately weak long-term

position. (See table below).

Capital Requirements:

Schedule 2 indicates total capital projects of $8,579,315, which includes

the CON application subject to this review and CON Applications 10102,

10103, and 10095. In addition to capital costs, the applicant is

projecting a year one operating loss for each of the above listed CONs

(see table below) which it will have to fund until profitability can be

achieved.


48

CON Number

Project Costs

Year One Operating Loss

10102 $2,204,540 $831,025

10103 $2,579,307 $1,158,762

10094 $1,913,485 $609,566

10095 $1,881,983 $924,318

Total $8,579,315 $3,523,671

Available Capital:

The applicant indicates on Schedule 3 of its application that funding for

the project will be provided by the parent. In support of the related

company financing, the applicant provided a letter from the parent

expressing it will provide the applicant financing from available cash on

hand and from an alternate source in the form of a $25,000,000 line of

credit from Regions Bank. The parent‟s 2009, audited financial

statements indicate $18.4 million in working capital and 6.3 million in

cash flows from operations. In addition, the applicant included a copy of

a letter from Regions Bank dated October 12, 2010, indicating a

revolving line of credit of $25,000,000 available. The line of credit is also

referenced in the parent‟s audit.

Staffing:

CONs 10094 and 10095 Position

FTEs Year One Ending May 2013

FTEs Year Two Ending May 2014

Administrator 1.00 1.00

Director of Nursing 1.00 1.00

Admissions Director 1.00 1.00

Secretary 1.00 1.00

Medical Records Clerk 1.00 1.00

Director of Business Development 1.00 1.00

Unit/Program Director 1.00 1.00

Psychiatrist 1.00 1.00

RN‟s 8.00 8.00

Mental health Techs 7.00 7.00

Psychologist 1.00 1.00

Social Service Director 1.00 1.00

Activity Director 1.00 1.00

Activities Assistant 1.00 1.00

Social Service Assistant 1.00 1.00

Total 28.00 28.00 Source: CON applications #10094 and #10095, Schedule 6.

Haven states the director of nursing and the director of social services

will be recruited. All clinical staff will be required to have experience in

geriatric or behavioral health settings.

Conclusion:

Funding for the projects and the entire capital budget should be

available as needed.


49

Haven Behavioral Services of Florida, LLC -- CON applications #10094 & #10095

Parent Parent

12/31/09 12/31/08

Current Assets (CA) $34,228,105 $38,454,397

Cash and Current Investment $8,786,777 $12,556,725

Total Assets (TA) $170,516,803 $175,144,100

Current Liabilities (CL) $15,838,729 $23,718,050

Total Liabilities (TL) $79,038,937 $80,611,977

Net Assets (NA) $91,477,866 $94,532,123

Total Revenues (TR) $106,536,563 $97,826,458

Interest Expense (Int) $4,391,041 $4,918,662

Excess of Revenues Over Expenses (ER) $131,925 $2,153,764

Cash Flow from Operations (CFO) $6,265,479 ($1,158,220)

Working Capital $18,389,376 $14,736,347

FINANCIAL RATIOS

12/31/09 12/31/08

Current Ratio (CA/CL) 2.2 1.6

Cash Flow to Current Liabilities (CFO/CL) 0.4 0.0

Long-Term Debt to Net Assets (TL-CL/NA) 0.7 0.6

Times Interest Earned (ER+Int/Int) 1.0 1.4

Net Assets to Total Assets (NA/TA) 53.6% 54.0%

Operating Margin (ER/TR) 0.1% 2.2%

Return on Assets (ER/TA) 0.1% 1.2%

Operating Cash Flow to Assets (CFO/TA) 3.7% -0.7%

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

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

A comparison of the applicant‟s estimates to the control group values

provides for an objective evaluation of financial feasibility, (the likelihood

that the services can be provided under the parameters and conditions

contained in Schedules 7 and 8), and efficiency, (the degree of economies

achievable through the skill and management of the applicant). In

general, projections that approximate the median are the most desirable,

and balance the opposing forces of feasibility and efficiency. In other

words, as estimates approach the highest in the group, it is more likely

that the project is feasible, because fewer economies must be realized to

achieve the desired outcome. Conversely, as estimates approach the

lowest in the group, it is less likely that the project is feasible, because a

much higher level of economies must be realized to achieve the desired

outcome. These relationships hold true for a constant intensity of service

through the relevant range of outcomes. As these relationships go

beyond the relevant range of outcomes, revenues and expenses may,

either, go beyond what the market will tolerate, or may decrease to levels

where activities are no longer sustainable.


50

Gross revenues, net revenues, and costs were obtained from Schedules 7

and 8 in the financial portion of the application and compared to the

control group as a calculated amount per adjusted patient day.

Haven Behavioral Services of Florida, LLC/CON #10094 (Brooksville)

will be compared to hospitals in the Short-Term Psychiatric Hospital

Group (Group 15). A case mix of 0.8417 was calculated for the

psychiatric discharges (non-surgical MDC 19, age 55 and over) in Citrus,

Hernando and Pasco Counties for 2009. Per diem rates are projected to

increase by an average of 2.7 percent per year. Inflation adjustments

were based on the new CMS Market Basket, 2nd Quarter, 2010.

Projected net revenue per adjusted patient day (NRAPD) of $650 in year

one and $728 in year two is between the control group median and

highest values of $611 and $739 in year one and $629 and $760 in year

two. With net revenues falling between the median and highest level, the

facility is expected to consume health care resources in proportion to the

services provided. (See table below).

Anticipated costs per adjusted patient day (CAPD) of $777 in year one

and $680 in year two is between the control group median and highest

values of $685 and $1,217 in year one and between the lowest and

median values of $515 and $705 in year two. With projected cost

between the median and highest value in the control group in year one,

and between the low and median values in year two, costs appear

reasonable. (See table below). The applicant is projecting a decrease in

CAPD between year one and year two from $777 to $680, or 12.4

percent. It should be noted that this application is for a new facility.

The first year of operation has a below average occupancy rate. The low

occupancy rate decreases economies of scale and as the occupancy rate

increases, CAPD would be expected to decrease.

The year two projected operating income for the project of $353,607

computes to an operating margin per adjusted patient day of $48, or 6.6

percent, which is between the control group median and highest values

of negative $33 and a positive $87.

Conclusion:

This project appears to be financially feasible.


51

Haven Behavioral Services of Florida, LLC

CON Application #10094 Dec-13 YEAR 2 VALUES ADJUSTED

2009 DATA Peer Group 15 YEAR 2 ACTIVITY FOR INFLATION

ACTIVITY PER DAY Highest Median Lowest

ROUTINE SERVICES 5,441,904 734 1,767 1,275 599

INPATIENT AMBULATORY 0 0 0 0 0

INPATIENT SURGERY 0 0 0 0 0

INPATIENT ANCILLARY SERVICES 249,421 34 241 0 0

OUTPATIENT SERVICES 0 0 289 18 0

TOTAL PATIENT SERVICES REV. 5,691,325 768 1,825 1,407 950

OTHER OPERATING REVENUE 0 0 70 1 0

TOTAL REVENUE 5,691,325 768 1,827 1,408 957

DEDUCTIONS FROM REVENUE 295,949 40 0 0 0

NET REVENUES 5,395,376 728 760 629 470

EXPENSES

ROUTINE 2,525,824 341 684 263 123

ANCILLARY 447,369 60 203 27 0

AMBULATORY 0 0 0 0 0

TOTAL PATIENT CARE COST 2,973,193 401 0 0 0

ADMIN. AND OVERHEAD 1,292,661 174 0 0 0

PROPERTY 615,571 83 0 0 0

TOTAL OVERHEAD EXPENSE 1,908,232 257 932 396 184

OTHER OPERATING EXPENSE 160,344 22 0 0 0

TOTAL EXPENSES 5,041,769 680 1,253 705 515

OPERATING INCOME 353,607 48 87 -33 -562

6.6%

PATIENT DAYS 7,411

ADJUSTED PATIENT DAYS 7,411

TOTAL BED DAYS AVAILABLE 8,760 VALUES NOT ADJUSTED

ADJ. FACTOR 1.0000 FOR INFLATION

TOTAL NUMBER OF BEDS 24 Highest Median Lowest

PERCENT OCCUPANCY 84.60% 94.7% 66.3% 18.8%

PAYER TYPE PATIENT

DAYS

% TOTAL

SELF PAY 385 5.2%

MEDICAID 0 0.0% 0.0% 0.0% 0.0%

MEDICAID HMO 0 0.0%

MEDICARE 6,210 83.8% 95.6% 49.0% 15.8%

MEDICARE HMO 445 6.0%

INSURANCE 371 5.0%

HMO/PPO 0 0.0% 71.5% 35.4% 2.4%

OTHER 0 0.0%

TOTAL 7,411 100%


52

Haven Behavioral Services of Florida, LLC/CON #10095 (Leesburg)

will be compared to hospitals in the Short-Term Psychiatric Hospital

Group (Group 15). A case mix of 0.7914 was calculated for the

psychiatric discharges (non-surgical MDC 19, age 55 and over) in Lake

and Sumter Counties in 2009. Per diem rates are projected to increase

by an average of 2.7 percent per year. Inflation adjustments were based

on the new CMS Market Basket, 2nd Quarter, 2010.

Projected net revenue per adjusted patient day (NRAPD) of $632 in year

one and $709 in year two is between the control group median and

highest values of $578 and $698 in year one and $595 and $719 in year

two. With net revenues falling between the median and highest level, the

facility is expected to consume health care resources in proportion to the

services provided. (See table below).

Anticipated costs per adjusted patient day (CAPD) of $837 in year one

and $664 in year two is between the control group median and highest

values of $648 and $1,151 in year one and between the lowest and

median values of $487 and $667 in year two. With projected cost

between the median and highest value in the control group in year one,

and between the low and median values in year two, costs appear

reasonable. (See table below). The applicant is projecting a decrease in

CAPD between year one and year two from $837 to $664, or 20.7

percent. It should be noted that this application is for a new facility.

The first year of operation has a below average occupancy rate. The low

occupancy rate decreases economies of scale and as the occupancy rate

increases, CAPD would be expected to decrease.

The year two projected operating income for the project of $357,194

computes to an operating margin per adjusted patient day of $45, or 6.4

percent, which is between the control group median and highest values

of negative $33 and a positive $87.

Conclusion:

This project appears to be financially feasible.


53

Haven Behavioral Services of Florida, LLC

CON Application #10095 Dec-13 YEAR 2 VALUES ADJUSTED

2009 DATA Peer Group 15 YEAR 2 ACTIVITY FOR INFLATION

ACTIVITY PER DAY Highest Median Lowest

ROUTINE SERVICES 5,636,092 717 1,670 1,206 566

INPATIENT AMBULATORY 0 0 0 0 0

INPATIENT SURGERY 0 0 0 0 0

INPATIENT ANCILLARY SERVICES 264,568 34 228 0 0

OUTPATIENT SERVICES 0 0 273 17 0

TOTAL PATIENT SERVICES REV. 5,900,660 751 1,725 1,331 898

OTHER OPERATING REVENUE 0 0 66 1 0

TOTAL REVENUE 5,900,660 751 1,728 1,331 904

DEDUCTIONS FROM REVENUE 324,536 41 0 0 0

NET REVENUES 5,576,124 709 719 595 445

EXPENSES

ROUTINE 2,440,144 310 647 249 116

ANCILLARY 469,519 60 192 25 0

AMBULATORY 0 0 0 0 0

TOTAL PATIENT CARE COST 2,909,663 370 0 0 0

ADMIN. AND OVERHEAD 1,523,439 194 0 0 0

PROPERTY 625,484 80 0 0 0

TOTAL OVERHEAD EXPENSE 2,148,923 273 881 375 174

OTHER OPERATING EXPENSE 160,344 20 0 0 0

TOTAL EXPENSES 5,218,930 664 1,184 667 487

OPERATING INCOME 357,194 45 87 -33 -562

6.4%

PATIENT DAYS 7,860

ADJUSTED PATIENT DAYS 7,860

TOTAL BED DAYS AVAILABLE 9,490 VALUES NOT ADJUSTED

ADJ. FACTOR 1.0000 FOR INFLATION

TOTAL NUMBER OF BEDS 26 Highest Median Lowest

PERCENT OCCUPANCY 82.82% 94.7% 66.3% 18.8%

PAYER TYPE PATIENT DAYS % TOTAL

SELF PAY 432 5.5%

MEDICAID 0 0.0% 0.0% 0.0% 0.0%

MEDICAID HMO 0 0.0%

MEDICARE 6,249 79.5% 95.6% 49.0% 15.8%

MEDICARE HMO 786 10.0%

INSURANCE 393 5.0%

HMO/PPO 0 0.0% 71.5% 35.4% 2.4%

OTHER 0 0.0%

TOTAL 7,860 100%


54

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

Haven Brooksville (CON #10094) & Haven Leesburg (CON #10095):

The project would introduce a new geriatric psychiatric provider to the

area.

General economic theory indicates that competition ultimately leads to

lower costs and better quality. However; in the health care industry

there are several significant barriers to competition:

Price-Based Competition is Limited - Medicare accounts for almost 50

percent of short-term psychiatric hospital charges in Florida, while

HMO/PPOs account for approximately 34 percent of charges. While

HMO/PPOs negotiate prices, fixed price government payers like Medicare

and Medicaid do not. Therefore price-based competition is limited to

non-government fixed price payers. Price-based competition is further

restricted as Medicare reimbursement in many cases is seen as the

starting point for price negotiation among non-government payers. In

this case, the applicant projects 76.8 percent of its projected patient days

will come from Medicare and 4.5 percent from Medicare HMO.

The User and Purchaser of Healthcare are Often Different – Roughly 84

percent of short-term psychiatric hospital charges in Florida are from

Medicare, Medicaid, and HMO/PPOs. The individuals covered by these

payers pay little to none of the costs for the services received. Since the

user is not paying the full cost directly for service, there is no incentive to

shop around for the best deal. In addition, users are restricted only to

the choices included in the insurance plan. This further makes price-

based competition irrelevant.

Information Gap for Consumers – Price is not the only way to compete for

patients, quality of care is another area in which hospitals can compete.

However, there is a lack of information for consumers and a lack of

consensus when it comes to quality measures. In recent years there

have been new tools made available to consumers to close this gap.

However, transparency alone will not be sufficient to shrink the

information gap. The consumer information must be presented in a

manner that the consumer can easily interpret and understand. The

beneficial effects of economic competition are the result of informed

choices by consumers.


55

In addition to the above barriers to competition, a study presented in The

Dartmouth Atlas of Health Care 2008 suggests that the primary cost

driver in Medicare payments is availability of medical resources. The

study found that excess supply of medical resources (beds, doctors,

equipment, specialist, etc.) was highly correlated with higher cost per

patient. Despite the higher costs, the study also found slightly lower

quality outcomes. This is contrary to the economic theory of supply and

demand in which excess supply leads to lower price in a competitive

market. The study illustrates the weakness in the link between supply

and demand and suggests that more choices lead to higher utilization in

the health care industry as consumers explore all alternatives without

regard to the overall cost per treatment or the quality of outcomes.

Conclusion:

Although a new provider for geriatric psychiatric care would be added to

District 3, due to the health care industry‟s existing barriers in consumer

based competition, this project will not likely have a material impact to

foster the type competition generally expected to promote quality and

cost-effectiveness.

f. Are the proposed costs and methods of construction reasonable? Do they comply with statutory and rule requirements? ss. 408.035(1)(h), Florida Statutes.; Ch. 59A-3 or 59A-4, Florida Administrative Code.


(Brooksville): The applicant proposes to establish a 24-bed adult

(geriatric) inpatient psychiatric hospital in a building formerly licensed as

Brooksville Regional Hospital. The new hospital would be located on part

of the first and third floors of the building. There is no indication that

the building will be owned by the applicant or another licensed

healthcare provider. This condition is not permitted under current state

regulations.

Neither the narrative nor the plans indicate the construction type of the

project. As a former hospital building, it is assumed that minimal

renovations will be required to meet the current fire life safety and

building construction type requirements. The plans and narrative

indicate that the patients will be located on the third floor of the building

and administrative areas will be located in a portion of the first floor

below the patient area. The use and layout of the floor directly beneath

the patient floor is not addressed by this submission. The Life Safety

Code (NFPA 101) requires that all floors located directly below a health


56

care occupancy be sub-divided into smoke compartments. This could

present a problem if the occupant of the second floor is not a healthcare

occupancy or did not grant access of the floor for the life safe use of the

hospital.

There is no mention of the disaster preparedness requirement of the

Florida Building Code (FBC). The exterior units (doors, windows,

louvers…) of the building will need to be protected from debris impact in

accordance with FBC 419.4.2.5. It is unclear from the information

submitted if existing exterior units meet the current code requirements.

The psychiatric nursing unit would consist of 12 semi-private patient

rooms. All patient rooms would have a toilet room that could be

accessed without going into the corridor. Some of the patient rooms

appear to be too small to comply with size requirement of the current

code when the area of the entry vestibule is subtracted from the room

area. Four patient rooms will have accessible patient toilet/shower

rooms. This will be sufficient to meet 10 percent accessibility

requirements for patient rooms. Other renovations will provide the

required patient tub rooms to serve patient room without bathing

facilities.

The new hospital does not appear to provide a nourishment station in

the psychiatric unit as required by code. There is no dietary department

shown on the plans, so it is assumed that meals will be prepared off site

and delivery to the facility by a food service vendor. Provision must be

made to protect from the weather food that is being delivered.

Most other required functional spaces for a psychiatric hospital have

been provided and are adequately sized. Direct nursing supervision of

the two seclusion rooms is not provided in the design. Modifications of

the layout will be needed to provide the direct supervision required by

code.

The project summary on the plan indicates that the project will comply

with current codes. Some additional architectural, mechanical and

electrical physical plant standards such as the nurse call, generator

requirements, and door hardware will need to be addressed as more

detailed construction documents are produced, but the physical

constraints of the spaces should accommodate these requirements.

The estimated construction costs for the project appear to be based on

an incomplete understanding of the scope of work. Additional work may

be needed to comply with current codes for a new hospital.


57

The design provides most of the required functional spaces, but there are

major concerns regarding the ownership and control of the portions of

the building that are part of the hospital. It may be necessary for the

applicant or another licensed hospital to purchase the entire building.

The architectural review of the application shall not be construed as an

in-depth effort to determine complete compliance with all applicable

codes and standards. The final responsibility for facility compliance

ultimately rests with the owner.

Haven Behavioral Services of Florida, LLC/CON #10095 (Leesburg):

The applicant proposes to establish a new 26-bed adult (geriatric)

inpatient psychiatric hospital within Leesburg Regional Medical Center-

North (the host hospital). The new hospital would be located on the first

floor of the host hospital. Renovations of existing nursing unit(s) being

used for storage would create the new psychiatric patient rooms and

required support spaces. Administrative spaces for the new hospital will

be in the host hospital‟s former surgical suite.


rooms and two private patient rooms. All patient rooms would have a

toilet room that could be accessed without going into the corridor. Both

private patient rooms exceed the current minimum area requirements.

All but one of the semi-private patient rooms appear to comply with the

size requirement of the current code. Two semi-private rooms will have

accessible patient toilet/shower rooms. This will be sufficient to meet 10

percent accessibility requirements for patient rooms. Other renovations

will provide the required patient showers and one patient tub room to

serve patient rooms without bathing facilities.

All required functional spaces for a psychiatric hospital have been

provided and are adequately sized. Some modifications will be necessary

to provide the direct nursing supervision required of the two seclusion

rooms.

The project summary on the plan indicates compliance with current

codes. Some additional architectural, mechanical and electrical physical

plant standards such as the nurse call, generator requirements, and

door hardware will need to be addressed as more detailed construction

documents are produced, but the physical constraints of the spaces

should accommodate these requirements.

The estimated construction costs and project completion forecast appear

to be reasonable.


58

The design as presented does not indicate any major impediments that

would prevent the design and construction of a code compliant facility.

It may be necessary to alter the plans to provide the required area for the

semi-private patient room or reduce the number of licensed beds by

eliminating a bed in the non-compliant patient room.

The architectural review of the application shall not be construed as an

in-depth effort to determine complete compliance with all applicable

codes and standards. The final responsibility for facility compliance

ultimately rests with the owner.

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.

Haven Brooksville (CON #10094) & Haven Leesburg (CON #10095):

The applicant is not an existing health service provider in Florida.

However, the applicant states that Haven Behavioral Services, Inc. has a

history of providing service to all patients regardless of payer class or

ability to pay. The applicant projects that charity care patient days will

represent 1.5 percent of total patient days. Charity care includes the

medically indigent as well as persons eligible for Medicaid and those who

receive services not covered by Medicaid, who are considered to be

financially indigent in accordance with the applicant‟s charity care

policy.

Haven Brooksville (CON #10094) - Schedule 7B and notes to the

schedule show that the applicant will be providing 13.7 percent of its

patient days to self-pay/charity/ other unreimbursed patients in year

one of operations. In year two of operations, the same schedule and

notes show that the applicant will be providing 5.2 percent of its patient

days to self-pay/charity/other unreimbursed patients.

Haven Leesburg (CON #10095) - Schedule 7B and notes to the schedule

show that the applicant will be providing 14.1 percent of its patient days

to self-pay/charity/other unreimbursed patients in year one of

operations. In year two of operations, the same schedule and notes show

that the applicant will be providing 5.5 percent of its patient days to self-

pay/charity/other unreimbursed patients.


59

F. SUMMARY


establish a 24-bed adult inpatient psychiatric hospital, at 55 Ponce de

Leon Avenue in Brooksville, Hernando County.

Total project is $1,913,485 and includes: building, equipment, project

development and start-up costs. The project involves 14,544 GSF of



establish a 26-bed adult inpatient psychiatric hospital-in-a-hospital at

Leesburg Regional Medical Center-North, in Leesburg, Lake County.

Total project is $1,881,983 and includes: building, equipment, project

development and start-up costs. The project involves 13,532 GSF of


Need




planning horizon.

As of June 11, 2010, District 3 had 209 licensed adult inpatient

psychiatric beds and no CON approved adult psychiatric beds pending.

District 3‟s licensed adult inpatient psychiatric beds experienced an

occupancy rate of 73.42 percent during the 12-month period ending

December 31, 2009.

The applicant, Behavioral Health Services of Florida, LLC, is applying to

establish new adult inpatient psychiatric hospitals - CON #10094 Haven

Brooksville with 24 beds in Hernando County and CON #10095 Haven

Leesburg with 26 beds in Lake County which exceed the seven beds in

the fixed need pool. The applicant is applying to what the applicant

considers “not normal” circumstances.

Haven Brooksville (CON #10094): The proposed service area is

Hernando and Citrus Counties (District 3) and northern Pasco Counties

(District 5).


60

Haven Leesburg (CON #10095): The proposed service area is Lake and

Sumter Counties.

Both: Haven states the need for geriatric psychiatric services is not being

met by existing providers in District 3. The applicant states “not normal”

circumstances are: District 3 and service area elderly receive

disproportionately less inpatient psychiatric care than other adults

mental health conditions in older adults are not being addressed, service

area nursing home residents have unaddressed behavioral health

disorders, dedicated geriatric psychiatric beds in the service area are

insufficient and Haven‟s focus on serving the geriatric psychiatric

population.

Specific to CON #10094 Haven - Brooksville states that as the only

provider of geriatric psychiatric inpatient care in the service area it

projects to provide 4,800 patient days of care in year one and 7,410 days

in year two.

Specific to CON #10095 Haven - Leesburg: The applicant states that as

the only provider of geriatric psychiatric inpatient care in the service area

it projects to provide 4,515 patient days of care in year one and 7,855

days in year two. The applicant projects occupancy in year two to be

82.8 percent.

Both: Per the applicant, two providers within the district have a

dedicated geriatric psychiatric unit or program – Springbrook Hospital

and The Vines. However, Haven does not address the occupancy of their

geriatric units or the programs they provide.

Haven anticipates an ALOS of 15 days during years one and two.



The age 65 and over ALOS is 8.76 days. Haven‟s projected ALOS is

approximately six days longer than CY 2009‟s.



The age 65 and over ALOS is 6.31 days. Haven‟s projected ALOS is

approximately eight days longer than CY 2009‟s.

The applicant‟s projected ALOS would exceed the national average of

12.4 days for patients in freestanding facilities by 2.6 days.


61

Haven‟s projected bed need is stated to be based on national use rates

applied to the service area and its historical discharge of a larger

percentage of its patients to nursing homes and ALFs than existing

service area providers. The use of a national use rate applied to the

service area does not demonstrate that existing providers are not meeting

the need. Haven does not document that patients in need of adult

inpatient psychiatric services are not able to access these services. It is

unclear how the applicant‟s historical discharge pattern could be used to

project more admissions.

Haven does not propose to be a Baker Act receiving facility.

For CON purposes, adult inpatient psychiatric services are evaluated for

patients age 18 and over; however, the applicant plans to serve patients

aged 55 and over. The applicant states that persons who are not

appropriate for admission at Haven will be referred to the appropriate

level of care. Callers who present with an emergency situation will be

advised to call 911.

Quality of Care

Haven Behavioral Services of Florida, LLC (CON #10094) and

(CON #10095) is a newly created entity and does not have a history of

providing care in the State of Florida. Haven states it has a history of

providing quality care and has received the gold seal of approval from

The Joint Commission in six of its hospitals. The applicant provides its

performance improvement plan that will be implemented, quality and

performance improvement activities, and a performance improvement

plan. Cost/Financial Analysis

Haven Behavioral Services of Florida, LLC/CON #10094 (Brooksville)

and CON #10095 (Leesburg): Funding for both projects and the entire

capital budgets should be available as needed. Assuming the applicant

will be able to meet the assumptions for patient days and payer mix,

both projects appear to be financially feasible.


62

Medicaid/Indigent Care

Haven Behavioral Services of Florida, LLC (CON #10094) and

(CON #10095): The applicant projects that charity care patient days will

represent 1.5 percent of total patient days. Haven states that charity

care includes the medically indigent as well as persons eligible for

Medicaid and those who receive services not covered by Medicaid, who

are considered to be financially indigent in accordance with the

applicant‟s charity care policy.

CON #10094 - Schedule 7B and notes to the schedule show that the

applicant will be providing 13.7 percent of its patient days to self-

pay/charity/other unreimbursed patients in year one and 5.2 percent of

year two‟s patient days to self-pay/charity/other unreimbursed patients.

CON #10095 - Schedule 7B and notes to the schedule show that the

applicant will be providing 14.1 percent of its patient days to self-

pay/charity/other unreimbursed patients in year one and 5.5 percent of

year two patient days to self-pay/charity/other unreimbursed patients.

Architectural Analysis Haven Behavioral Services of Florida, LLC/CON #10094

(Brooksville): With no indication that the building will be owned by the

applicant or another licensed healthcare provider, this is not permitted

under current State regulations. It may be necessary for the applicant or

another licensed hospital to purchase the entire building.


rooms; however, some of these rooms appear to be too small to comply

with size requirement of the current code.

Neither the narrative nor the plans indicate the construction type of the

project. The use and layout of the floor directly beneath the patient floor

is not addressed and the Life Safety Code (NFPA 101) requires that all

floors located directly below a healthcare occupancy be sub-divided into

smoke compartments. There is also no mention of the disaster

preparedness requirement. The plans do not appear to provide for a

nourishment station, as required by code (with no other provisions stated

Direct nursing supervision of the two seclusion rooms is not provided in

the design.

The project summary on the plan indicates that the project will comply

with current codes.


63

The estimated construction costs for the project appear to be based on

an incomplete understanding of the scope of work.

Haven Behavioral Services of Florida, LLC/CON #10095 (Leesburg):


rooms and two private patient rooms.

The project summary on the plan indicates compliance with current

codes.

The estimated construction costs and project completion forecast appear

to be reasonable.

G. RECOMMENDATION

Deny CON #10094 and CON #10095.


64

AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration

adopted the recommendation contained herein and released the State

Agency Action Report.

DATE:

James B. McLemore Health Services and Facilities Consultant Supervisor Certificate of Need

Jeffrey N. Gregg Chief, Bureau of Health Facility Regulation

Date post:	30-Oct-2020
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