STATE AGENCY ACTION REPORTahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10091.pdf · assisted living facility), and South Hialeah Manor, a 67-bed assisted living facility, and executive

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Compassionate Care Hospice of Florida, Inc./CON #10091

200 Lanidex Plaza, Suite 2101

Parsippany, New Jersey 07054

Authorized Representative: Judith Grey

(973) 402-4712

2. Service Area/Subdistrict

District 11, Hospice Service Area 11, Miami-Dade and Monroe Counties

B. PUBLIC HEARING

A public hearing was not held or requested regarding the proposal to

establish a hospice program in Hospice Service Area 11. However,

Compassionate Care Hospice of Florida, Inc. has 47 letters in support of

its application. Forty-three of these are from Service Area 11 including

representatives of eight hospitals (one dated December 2008) 23 skilled

nursing facilities, 16 assisted living facilities, three community

organizations, the Borinquen Health Care Center, Inc. and four

physicians. Three letters are from out of state. Three physician letters

are dated December 2008.

Norman J. Ginsparg, Director of Legal Affairs of four skilled nursing

facilities in Miami-Dade County (Nursing Center at Mercy, Harmony

Health Center, Fair Havens Center, and Oceanside Extended Care)

states, “we understand Compassionate Care has a successful track

record in educating Hispanic patients and families on selecting hospice

services during the end of their life and believe relevant experience could

assist in increasing the relatively low penetration rate in Miami-Dade

County.”

CON Action Number: 10091

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Palmetto General Hospital CEO, Ana Mederos, M.B.A., Lower Keys

Medical Center CEO, Nicki Lyn Will, Ph.D., Fishermen‟s Hospital CEO,

Kimberly Bassett, Kindred Hospitals South Florida, Executive Director,

Theodore L. Welding (representing Kindred Hospital Coral Gables), and

Larkin Community Hospital CEO, Jack J. Michel, M.D., indicate that

they are willing to enter into agreements with Compassionate Care to

provide inpatient hospice care and specific to Kindred, provide

Compassionate Care as an option in the discharge planning process.

Six Miami-Dade County community nursing home executives indicate

their willingness to enter into agreements for inpatient services and/or

the possible creation of an inpatient unit. These include Norman J.

Ginsparg, Director of Legal Affairs on behalf of The Nursing Center at

Mercy, Harmony Health Center, Fair Havens Center, Oceanside Extended

Care Center; Michael Bokor, CEO of Southern SNF Management on

behalf of Palmetto Rehabilitation and Health Center; Aaron Hollander,

CFO, on behalf of Claridge House Nursing and Rehabilitation Center and

Regents Park at Aventura; David Gold, NHA, Administrator of North

Beach Rehabilitation Center; Samuel Tate, Administrator, Hampton

Court Nursing & Rehabilitation Center and Verma Johnson,

Administrator, Homestead Manor.

Claudia Pace, NHA, Administrator for Courtyard Manor Retirement

Living (an 86-bed assisted living facility), La Hacienda Gardens (a 48-bed

assisted living facility), and South Hialeah Manor, a 67-bed assisted

living facility, and executive manager for Eden Gardens (a 118-bed

assisted living facility), Flamingo Park Manor (a 72-bed assisted living

facility), and North Miami Retirement Living (a 50-bed assisted living

facility), states that she is willing to execute an agreement with

Compassionate Care for each of the six facilities to enable them to care

for their hospice appropriate residents. The applicant had letters from

eight ALF operators of facilities ranging from six to 12 beds.

C. PROJECT SUMMARY

Compassionate Care Hospice of Florida, Inc. (CON #10091) proposes

to establish a new hospice program in Hospice Service Area 11, Miami-

Dade and Monroe Counties. Compassionate Care Hospice was founded

in 1993. Over the past 17 years Compassionate Care Hospice has

developed 24 hospice programs in 16 states: Delaware, Georgia, Illinois,

Kansas, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey,


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New York, Pennsylvania, South Carolina, South Dakota, Texas, Virginia

and Wisconsin. Compassionate Care Hospice has been approved to

establish a hospice program in Subdistrict 6B, Polk, Hardee, and

Highlands Counties.

The applicant is proposing total project costs of $141,950 with year one

operating costs of $1,527,651 and year two costs of $4,561,439.

Schedule C includes the following conditions:

As required by law, Compassionate Care Hospice is willing to accept any

such conditions on its CON-based on any representations made through

this CON application.

Compassionate Care will provide all the required components of hospice

care, and meet all Medicare conditions of participation, and Florida

hospice licensure requirements, including the provision of all levels of

service (routine home care, continuous care, general inpatient, respite) to

all types of patients without regard to race, ethnicity, gender, age,

religious affiliation, diagnosis, financial status, insurance status, or any

other discriminating factor.

1. Compassionate Care Hospice of Florida will implement a

concentrated outreach program for assisted living facilities (ALFs)

and will visit all licensed ALF providers, regardless of size, in the

first year of operation, and will provide educational information to

such ALFs in the language suitable for the facility staff and

residents. Compliance will be measured by a signed declaratory

statement submitted to the Agency.

2. Compassionate Care Hospice of Florida will implement its Hispanic

Outreach Program immediately upon licensure. Compliance will

be measured by a signed declaratory statement submitted to the

Agency.

3. At least 50 percent of all interdisciplinary team members in

District 11 consisting of physicians, registered nurses, home

health aides, social workers, chaplains, and volunteers, will be

bilingual (English and Spanish). Compliance will be measured by

a signed declaratory statement submitted to the Agency.


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4. Compassionate Care Florida will work with local Hispanic

organizations including The Borinquen Health Care Center, The

League Against Cancer and the South Florida Hispanic Chamber of

Commerce to enhance the overall hospice penetration amongst

Hispanics through education and awareness. Compliance will be

measured by a signed declaratory statement submitted to the

Agency.

5. Compassionate Care Florida will implement its Cardiac

Connections Program in District 11 within year one of operation.

Compliance will be measured by a signed declaratory statement

submitted to the Agency.

6. Compassionate Care Hospice of Florida has conditioned approval

of this application on the provision its main office will be located in

Hialeah, Miami-Dade County, a city that is more than 81 percent

Hispanic. The applicant received eight letters of support for its

application from facilities in Hialeah. Compliance will be measured

by a signed declaratory statement submitted to the Agency.

7. Compassionate Care Hospice of Florida has conditioned approval

of this application to the provision it will open a satellite office in

Marathon, Monroe County during its first year of operation.



8. Compassionate Care Florida has conditioned approval of this

application on the provision it will provide one FTE life

enhancement specialist. Compliance will be measured by a signed

declaratory statement submitted to the Agency.

9. Compassionate Care Florida has conditioned approval of this

application on the provision it will provide one FTE homemaker.



10. Compassionate Care Florida will condition approval of this

application on the provision it will become accredited by CHAP

upon certification. Compliance will be measured by submission of

accreditation certificate to the Agency.


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11. Compassionate Care Hospice Group, Ltd will implement its

Pathways to Compassion Program immediately upon licensure of

Compassionate Care Hospice of Florida, which will be made

available to all eligible District 11 residents. Compliance will be

measured by a signed declaratory statement submitted to the

Agency.

12. Compassionate Care Florida will provide a home health aide ratio

above NHPCO guidelines at an average of 10 hours per patient per

week. Compliance will be measured by a signed declaratory

statement submitted to the Agency.

Hospice programs are required by federal and state law to provide services

to everyone requesting them and therefore the Agency would not place

conditions on a program to provide legally required services.

The applicant’s proposed conditions are as it stated. However, Section

408.043 (4) Florida Statutes states that “Accreditation by any private

organization may not be a requirement for the issuance or maintenance of a

certificate of need under ss. 408.031-408.045.”

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. Section 408.606 (5) Florida

Statutes states that “The agency may deny a license to an applicant that

fails to meet any condition for the provision of hospice care or services

imposed by the agency on a certificate of need by final agency action,

unless the applicant can demonstrate that good cause exists for the

applicant’s failure to meet such condition”.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review

criteria found in Section 408.035, Florida Statutes, rules of the State of

Florida, and Chapters 59C-1 and 59C-2, Florida Administrative Code.

These criteria form the basis for the goals of the review process. The

goals represent desirable outcomes to be attained by successful

applicants who demonstrate an overall compliance with the criteria.

Analysis of an applicant's capability to undertake the proposed project

successfully is conducted by evaluating the responses provided in the

application, and independent information gathered by the reviewer.


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Applications are analyzed to identify various strengths and weaknesses

in each proposal. If more than one application is submitted for the same

type of project in the same district (subdistrict or service planning area),

applications are comparatively reviewed to determine which applicant

best meets the review criteria.

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

amendments once an application has been deemed complete. The

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

such, the applicant is responsible for the representations in the

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

certification of the applicant.

As part of the fact-finding, the consultant, Cheslyn Green, analyzed the

application in its entirety with consultation from financial analyst,

Derron Hillman, who evaluated the financial data. E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed projects

with the criteria found in Florida Statutes, Sections 408.035 and

408.037; applicable rules of the State of Florida, Chapter 59C-1 and

59C-2, Florida Administrative Code.

1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed

need pool? Chapter 59C-1.008, Florida Administrative Code and Chapter 59C-1.0355, Florida Administrative Code.

In Volume 36, Number 13 of the Florida Administrative Weekly, dated

April 2, 2010 the Agency for Health Care Administration (the Agency)

indicated a hospice program net need of zero for Hospice Service Area 11

for the July 2011 Hospice Planning Horizon. Hospice Service Area 11 is

currently served by Catholic Hospice, Inc., Hospice Care of South

Florida, Hospice of the Florida Keys, Inc., VITAS Healthcare Corporation

of Florida, HospiceCare of Southeast Florida, Inc., Douglas Gardens

Hospice, Inc., and Odyssey Healthcare.


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HCR Manor Care Services of Florida II, Inc. has CON #10043 approved

but yet to be licensed to establish a hospice program in Service Area 11.

Rule 59C-1.0355 (4)(c) Florida Administrative Code, states that the

Agency shall not normally approve another hospice program for any

service area that has an approved hospice program that is not yet

licensed. Regardless, the applicant is applying to establish a hospice

program in the absence of published numeric need. b. Approval Under Special Circumstances. In the absence of numeric

need shown under the formula in paragraph (4)(a), the applicant must demonstrate that circumstances exist to justify the approval of a new hospice. Chapter 59C-1.0355 (4)(d), Florida Administrative Code. Evidence submitted by the applicant must document one or more of the following:

1. The specific terminally ill population is not being served. 2. That a county or counties within the service area of a licensed

program are not being served. 3. That there are persons referred to hospice programs who are

not being admitted within 48 hours (excluding cases when a later admission date has been requested). The applicant shall indicate the number of such persons.

Compassionate Care Hospice of Florida, Inc. does not directly

respond to the above criteria but indicates the not normal and

special circumstances it describes in its need discussion below

support approval of the project.

c. Other Special Circumstances.

The applicant presents an overview of the special and not normal

circumstances that it states exist in Service Area 11. The applicant

states that the gap in hospice admissions in Service Area 11 is so vast

that it would be sufficient to warrant almost nine new hospice providers

based on the Agency‟s traditional 350 threshold (3,013/350= 8.6).

However, because Service Area 11 has one approved hospice program

any additional need is negated for two years from the date of the new

program‟s licensure.


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District 11 Hospice Utilization

Current Utilization and Projected Need July 2011 Batching Cycle

District 11 Providers U65C 65C U65NC 65NC Total

Projected Hospice Patients 1,188 2,889 912 7,320 12,309

Catholic Hospice Inc. 180 595 59 990 1,823

Douglas Gardens Hospice, Inc. 13 66 28 128 235

HospiceCare of Southeast Florida, Inc. 22 75 19 252 368

Hospice of South Florida 2 37 5 110 154

Hospice of the Florida Keys, Inc. 29 58 8 80 175

VITAS Healthcare Corporation of Florida 603 1,526 301 3,231 5,661

Odyssey Healthcare 14 138 41 686 880

Current District 11 Utilization 863 2,494 461 5,478 9,296

Projected Minus Current 325 395 451 1,842 3,013

Need Projected Minus Current Hospice Patients >350 1

Approved Hospice Providers for District 11 1

Net Need 0 Source: CON Application #10091, page 10.

The applicant states that the most significant numeric gap in services is

within non-cancer patients age 65 and older. The applicant states that

this gap in services is enough to warrant a need for more than five

hospice programs (1,842/350= 5.3). The under 65 non-cancer cohort

represents the second largest gap in service reflecting a 451 projected

gap in admissions. The applicant states that each of these population

and disease categories individually warrant approval of an additional

hospice provider; but together they are represent a gap in admissions of

720, which is sufficient to trigger a need for two hospices (720/350=2.1).

The following table illustrates hospice penetration rates for Service Area

11 compared to statewide hospice penetration rates for each of the

age/diagnosis cohorts.

District 11 Hospice Penetration Rate Current Utilization and 2007 Deaths

District 11 U65C 65C U65NC 65NC Total

Hospice Admissions 863 2,494 461 5,478 9,296

2007 Resident Deaths 1,188 2,836 3,946 10,363 18,606

District 11 Hospice Penetration Rates 72.7% 87.9% 11.7% 51.5% 50.0%

Statewide

Hospice Admission 10,494 27,513 7,107 61,784 106,898

2007 Resident Deaths 11,132 28,634 32,595 95,169 167,530

Statewide Hospice Penetration rate 94.3% 96.1% 21.8% 64.9% 63.8%

District 11 Short Fall 21.9% 8.2% 10.1% 13.4% 13.8% Source: CON Application #10091, page 11.

The applicant‟s table above demonstrates that Service Area 11 has lower

penetration rates compared to the statewide penetration rates in each of

the four age/disease categories. Compassionate Care states that based

on its needs analysis, it has identified specific terminally ill populations

which are in need of hospice services and significantly underserved, each


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individually supporting the need for an additional hospice provider. The

applicant identifies special circumstances as people residing in small

assisted living facilities that are largely ignored and overlooked by

existing hospice providers, Hispanic terminally-ill individuals, terminally-

ill cancer individuals of all ages and terminally-ill with non-cancer

diagnoses of all ages as significantly underserved populations. The

applicant asserts there is more than sufficient need in Service Area 11 to

support two new successful programs (HCR Manor Care and

Compassionate Care Hospice of Florida).

The applicant states that for more than the past 15 years the Agency has

consistently published a projected gap in hospice admissions in Service

Area 11 that exceeds the 350 admission threshold. In the past eight

batching cycles, this projected gap in admissions has exceeded 3,000.

Yet, a need for one additional hospice provider can only be published

after an approved program has been licensed for at least two years. The

applicant states that in CON Application #10043, HCR projects it will

serve 321 patients in its first year, 437 in its second year and 502

patients in year three based on what it refers to as the Florida experience

and the experience of the existing providers in Service Area 11.

Compassionate Care Hospice states that assuming HCR attains its

projected year three admissions, there will still be a tremendous gap in

projected admissions of 2,511 remaining (3,013-502=2,511); at the point

when this new provider has been licensed for two years, need will be

published once again. This will further feed into the Service Area 11

cyclical pattern of enormous need and very short supply rather than a

more balanced approach to supply and demand. The applicant states

that the not normal circumstance is a programmatic and cultural access

problem and is evident in the exorbitant gap in projected hospice

admissions in Service Area 11. Compassionate Care contends that this

situation is persistent and irreparable unless a second new provider is

awarded a CON to develop a program in Miami-Dade and Monroe

Counties. Compassionate Care Hospice states this not normal

circumstance is the result of the Hispanic terminally-ill population that

is not being fully served by existing providers. Compassionate Care

Hospice asserts it is fully committed to ameliorating this not normal

circumstance and addressing the special circumstances.

Terminally-Ill Residing in Small Assisted Living Facilities

The applicant states that Miami-Dade and Monroe Counties have 981

assisted living facilities (ALFs) with 10,379 licensed beds. Of the 981

ALFs, 937 of them have 30 licensed beds or fewer and 835 of them are

licensed for 10 or less beds. The 835 ALFs with 10 or less beds have an


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aggregate 5,071 licensed beds; these represent 49 percent of all ALF

beds. According to the applicant these smaller ALFs are a main driver of

the lower hospice penetration rate. There appears to be a lack of

education and outreach in the small individual ALFs. The applicant

states that existing providers appear not to be focusing on reaching out

to these small facilities largely due to the number of potential residents

contacted in an educational and support visit is disproportionately low

compared to larger facilities (85 percent of the facilities represent 49

percent of the beds). Therefore, the applicant states the existing

providers are focusing on the larger institutions (15 percent of the

facilities with 51 percent of the beds) where it is easier and more

economical to conduct education, outreach, and to provide care.

The applicant states that based on interviews and community feedback,

many of the small ALFs have a fundamental misunderstanding about

hospice. They generally do not understand that the resident does not

lose other funding sources by choosing hospice and that opting for

hospice service does not result in the resident‟s relocation to another

facility. The applicant has conditioned its application on the provision it

will implement a concentrated outreach program for assisted living

facilities and will visit all licensed ALF providers, regardless of size, in the

first year of operation. It will also will provide educational information to

such ALFs in the language suitable for the facility staff and residents.

The applicant states that many of these smaller ALFs are located in

Hialeah and as such it will locate its main office in Hialeah. The

applicant has 10 letters of support from Service Area 11 ALFs with 12 or

fewer beds: The Haven (six beds), Home for the Angels (six beds), A

Loving Place (12 beds), Seraphim Care, Inc. (eight beds), All USA Homes,

Inc. (six beds), Ady‟s Family Home (six beds), Carely Home Care (six

beds), Abuelitas Home (six beds), A Home Away from Home (six beds),

and Casita Amor Care (six beds). These letters do not document that

hospice services in Service Area 11 are not available or accessible to

residents of small ALFs.

Hispanic Terminally-Ill Population

The applicant states Hispanics are the largest ethnic population in

Service Area 11 yet they are the least likely cohort to utilize hospice

services. A recent study by Karen Andersen, et. al. in The Journal of

Pain titled, Racial and Ethnic Disparities in Pain: Causes and

Consequences of Unequal Care, found “persistence of racial and ethnic

disparities in acute, chronic, cancer, and palliative pain across the

lifespan and treatment settings, with minorities receiving lesser quality

pain care then non-Hispanic whites.” The applicant states that racial

and ethnic disparities in acute pain, chronic cancer pain and palliative


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pain care continue to persist. The study states that non-minority

patients are more likely to enroll in hospice than minority patients.

Specifically, six percent of patients in the United States enrolled in

hospice care are Hispanic. The applicant states that most patients

receiving Medicare hospice benefits are non-Hispanic whites. One

contributing factor to such low utilization is that Hispanic patients and

providers have limited knowledge of hospice programs and goals.

Compassionate Care notes that cultural attitudes and beliefs

surrounding end-of-life care may adversely affect hospice enrollment.

The word hospice in Spanish translates into “hospicio” which refers to a

place such as an asylum related to poverty and abandonment. The

applicant states that the word hospicio has a negative connotation that

makes many Hispanic individuals reject the concept before they have

invested any time or effort into learning about it. The cultural disparities

between Hispanics and non-Hispanics are apparent in the tendency for

the terminally-ill to not utilize end-of-life care.

Compassionate Care states that the percentage of deaths among

Hispanics in both Miami-Dade and Monroe Counties is on the rise, while

the percentage of non-Hispanic deaths is slowly declining. During CY

2008, Hispanic deaths were 58 percent (10,728) of the (18,635) deaths in

the district.

District 11 Resident Deaths

Hispanic versus Non-Hispanic Deaths 1999 and 2008

Hispanic Deaths CY 1999 Deaths CY 2008 Deaths 10-Year Change

Ages 0 to 64 2,079 2,283 9.8%

Ages 65+ 7,139 8,445 18.3%

Total 9,218 10,728 16.4%

Non-Hispanic Deaths

Ages 0 to 64 3,144 2,689 -14.5%

Ages 65+ 7,477 5,218 -30.2%

Total 10,621 7,907 -25.6%

Total Deaths

Ages 0 to 64 5,223 4,972 -4.8%

Ages 65+ 14,616 13,663 -6.5%

Total 19,839 18,635 -6.1%

Hispanic as % of Total 46.5% 57.6% --

Source: CON Application #10091, page 31.

Compassionate Care states that 48.7 (2,226 discharges/4,570

discharges) percent of all hospital discharges to hospice were Hispanic

even though Hispanic deaths accounted for 59.2 percent of Miami-Dade


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County‟s total deaths. Hispanic hospice discharges are 48.5 percent

(2,228 discharges/4,594 total discharges) and Hispanic deaths 57.6

percent (10,728/18,635) of the service area total. Compassionate states

the shortfall in Hispanic discharges to hospice represents a significant

volume of underserved patients.

District 11 Hispanic Deaths and Admissions to Hospice

Calendar Year 2009

Hispanic Cohort

District 11 Total

Miami-Dade County

Monroe County

Hispanic Percent of Total Deaths (A) 57.6% 59.2% 11.4%

Total Discharges from Hospital to Hospice (B) 4,594 4,570 24

Hispanic Discharges from Hospital to Hospice (C) 2,228 2,226 2

Hispanic % of Discharges to Hospice From Hospital (B

– C = D)

48.5%

48.7%

8.3%

Hospice Shortfall (A – D = E) -- 10.5% 3.1%

Additional Volume (E * B = F) 481 480 1

Restated Hispanic Discharges to Hospice with

Shortfall (C + F)

2,709

2,706

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Source: CON Application #10091, page 33.

The chart above indicates that the applicant‟s „shortfall‟ is the 10.5

percent less Hispanic hospital discharges to hospice compared to non-

Hispanic hospital discharges to hospice in Miami-Dade. Applying the

non-Hispanic (10.5 percent difference) discharge rate to the Hispanic

discharges results in an additional 481 Hispanic hospital discharges to

hospice.

District 11 Hispanic Deaths and Admissions to Hospice Calendar Year 2009

Hispanic Cohort District 11 Total

Total Hospice Admissions 9,296

Less Discharges from Hospital to Hospice 4,594

Remaining Hospice Admissions (G) 4,702

Percent Hispanic (D) 48.5%

Shortfall (E) 10.5%

Additional Volume (G * E = I) 494

Total Additional Hispanic Hospice Admission (F + I) 975 Source: CON Application #10091, page 33.

Compassionate states that in 2009 there were 9,296 total hospice

admissions; of those, 4,702 were admitted from either home or from

another non-hospital location. The applicant applies the 10.5 percent

„shortfall‟ above and concludes there would have been 494 additional

Hispanic hospice admissions from home, skilled nursing facilities,

assisted living facilities and any other non-hospital setting.

Compassionate Care concludes that there would have been 975

additional Hispanic admissions to hospice for all settings.


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Compassionate Care states this deficiency suggests that there is a

disproportionately low utilization by Hispanics, and increasing them to

the same level as non-Hispanics accounts for approximately one third of

the published numeric shortfall of 3,013. The applicant states that

Compassionate Care Hospice has the skill set to meet the needs of

Service Area 11‟s Hispanic population, including the specific

programming for each of the identified terminal illnesses that are

prevalent in this Hispanic community. The applicant provides excerpts

from local Hispanic support letters, out of state Hispanic support letters,

a description of its success in other states and a detailed description of

its proposed Hispanic out-reach program. These letters support

Compassionate Care‟s ability to outreach to the Hispanic community.

They do not document that hospice services in Service Area 11 are not

available or accessible to the Hispanic community. Compassionate Care

Hospice concludes that its skill set to admit, manage and treat Hispanic

patients in a most culturally sensitive way will enhance overall hospice

penetration for Hispanic terminally-ill residents.

Terminally-Ill Non-Cancer Patients

The applicant states that the greatest numeric gap in Service Area 11

hospice admissions falls within the non-cancer patient population. Of

the 3,013 total projected gap in hospice admissions, 76 percent will be

non-cancer. Compared to the State of Florida, the Service Area 11 non-

cancer hospice penetration rate is 10.1 percent lower in the under 65

years of age cohort, and 13.4 percent lower than the state in the 65 and

older cohort.


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District 11 Non-Cancer Penetration Rate

2009 Hospice Admissions and 2007 Resident Deaths1

District 11

Under 65 Non-Cancer

65 and Older Non-Cancer

Total Non-Cancer

District 11 Hospice Admissions 461 5,478 5,939

2007 Resident Deaths 3,946 10,636 14,582

Hospice Penetration Rate 11.7% 51.5% 40.7%

Florida

Hospice Admissions 7,107 61,784 68,891

2007 Resident Deaths 32,595 95,169 127,764


District 11 Shortfall 10.1% 13.4% 13.2% Source: CON Application #10091, page 42 from Florida Need Projections, April 2, 2010 and NHA Analysis. Note: The applicant’s table included ‘District X’ Hospice Admissions in ‘District 11’ and in the ‘Florida’ Hospice admissions on pages 42 and 46, which we have corrected and deleted.

District 11 Projected Non-Cancer Hospice Admissions

July 2011 Planning Horizon

District 11

Under 65 Non-Cancer

65 and Older Non-Cancer

Total Non-Cancer

Projected Hospice Patients 912 7,320 8,232

Current District 11 Utilization 461 5,478 5,939

Projected Minus Current 451 1,842 2,293 Source: CON Application #10091, page 43.

The applicant states that the 2,293 gap in projected non-cancer hospice

admissions noted above suggest that with just non-cancer patients, there

is a need for at least six additional hospices (2,293/350= 6.6). The non-

cancer gap in service alone is a much greater gap in admissions that any

other hospice service area has statewide. Compassionate Care does not

document that hospice services are not available or accessible to this

Service Area 11 population.

Hispanic Non-Cancer Terminally-Ill

While cancer accounts for 2,337 annual deaths in Service Area 11 which

is the second most common disease, it is heart disease that is the most

common cause of death amongst Hispanic residents of Service Area 11.

Heart disease accounts for 29.2 percent of total Hispanic deaths in

Miami-Dade and Monroe Counties. Compassionate Care Hospice states

this significantly increases among the 65 and older cohort, representing

32.3 percent of all Hispanic deaths. Chronic lower respiratory disease is

the third most significant cause of death, accounting for 4.6 percent of

1 The applicant notes that its hospice admissions numbers are based AHCA publication and on „NHA analysis‟. The Agency does not require hospices that serve multiple service areas to provide the breakout of the under age 65/age 65 and over/cancer/non-cancer admissions for individual service areas they serve. Therefore, the applicant apparently assigns certain percentages to SA 11 residents served by three of the seven hospices as these three hospices serve more than one service area.


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2008 Hispanic deaths. Diabetes and Alzheimer‟s disease are both quite

prevalent in the Hispanic community representing 3.8 and 3.2 percent of

total Hispanic deaths, respectively.

District 11 Hispanic Deaths and Percent of

Total 2008 Deaths

Hispanic Deaths by Disease Ages 0-64 Ages 65+ Total

Cancer 622 1,715 2,337

Heart Disease 404 2,731 3,135

Diabetes 89 318 407

Alzheimer‟s Disease 2 343 345

Chronic Lower Respiratory 43 453 496

All Other 1,123 3,885 4,008

Total 2,283 8,445 10,728

Percent of Total

Cancer 27.2% 20.3% 21.8%

Heart Disease 17.7% 32.3% 29.2%

Diabetes 3.9% 3.8% 3.8%

Alzheimer‟s Disease 0.1% 4.1% 3.2%

Chronic Lower Respiratory 1.9% 5.4% 4.6%

All Other 49.2% 34.2% 37.4%

Total 100.0% 100.0% 100.0% Source: CON Application #10091, page 44.

The applicant states that though Hispanics represent nearly 58 percent

of Service Area 11‟s total deaths, they account for a disproportionate

share of Service Area 11 deaths in several non-cancer specific disease

categories. The table below shows Hispanic deaths as the percent of the

District‟s total deaths.

District 11 Hispanic Deaths as Percent of the District’s Total

2008 Deaths

Disease Ages 0-64 Ages 65+ Total

Cancer 52.1% 59.2% 57.1%

Heart Disease 44.9% 62.6% 59.6%

Diabetes 47.8% 66.4% 61.2%

Alzheimer‟s Disease 66.7% 67.0% 67.0%

Chronic Lower Respiratory 49.4% 63.3% 61.8%

All Other 46.0% 60.6% 55.7%

Total 45.9% 61.8% 57.6% Source: CON Application #10091, page 44.

As shown above, Hispanics account for 67 percent of all Service Area 11

deaths caused by Alzheimer‟s Disease. Compassionate Care states the

next greatest disparity is among chronic lower respiratory related deaths;

Hispanics account for nearly 62 percent of Service Area 11‟s deaths2.

While Compassionate Care contends there are cultural access problems,

it does not document that hospice services are not available or accessible

to Service Area 11‟s Hispanic population.

2 CON Application #10091, page 44.


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Terminally-Ill Cancer Patients

Compassionate Care states Service Area 11 has more than 4,000 cancer

(4,024 in CY 2007) related deaths; of those 3,358 actually received

hospice care representing an 83.4 percent hospice penetration rate3. The

State of Florida average hospice penetration rate for cancer patients is

95.6 percent (38,007 admissions/39,766 deaths) representing a 12.2

percent difference based on 2007 deaths applied to 2009 hospice

admissions. The applicant states the under 65 age cohort in Service

Area 11 has a hospice penetration rate shortfall of nearly 22 percent and

the 65 and older cohort has a shortfall of eight percent; essentially 666

terminally-ill patients in Service Area 11 go without end-of-life care,

according the applicant4.

District 11 Cancer Hospice Penetration Rate

2009 Hospice Admissions and 2007 Resident Deaths

District 11

Under 65 Cancer

65 and Older Cancer

Total Cancer

District 11 Hospice Admissions 863 2,494 3,358

2007 Resident Deaths 1,188 2,836 4,024


Florida

Hospice Admissions 10,494 27,513 38,007

2007 Resident Deaths 11,132 28,634 39,766


District 11 Shortfall 21.6% 8.2% 12.2% Source: CON Application #10091, page 46.

The applicant used total oncology discharges from hospitals to assess the

percentage of patients that were discharged/transferred to hospice for

Service Area 11 and found that the service area had the greatest number

of oncology related hospital discharges (8,193) of any other hospice

service area. Service Area 11 also had the greatest number of oncology

discharges to hospice (900). However the applicant states Service Area

11 is lowest statewide in the percent of total oncology patients

discharged to hospice, 11 percent5 (900/8,193). Compassionate Care

does not document that hospice services are not available or accessible

to this Service Area 11 population.

3 The applicant‟s hospice admissions numbers are based AHCA publication and on „NHA analysis‟. The Agency does not require hospices that serve multiple service areas to provide the breakout of the under age 65/age 65 and over/cancer/non-cancer admissions for individual service areas they serve. Therefore, the applicant apparently assigned a certain percentage to SA 11 residents served by three of the seven hospices as these three hospices serve more than one area. 4 District 11 Cancer Hospice Penetration Rate 2009 Hospice Admission and 2007 Resident Deaths, CON Application #10091, page 46. 5 Statewide Oncology Discharges and Percent Discharged to Hospice Calendar Year 2009, CON Application #10091, page 47.


17

Compassionate Care anticipates it will serve 219 hospice patients in year

one, and 606 in year two. Projected market shares were applied to the

projected total hospice admissions to calculate the number of admissions

by category and age that Compassionate Care would serve. Rates are

generally based on the experience of other hospices in Florida. The

applicant states that the average lengths of stay are expected to be 35

days and 65 days in years one and two respectively.

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

a New Hospice Program. The Agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs:

(1) Preference shall be given to an applicant who has a

commitment to serve populations with unmet needs.

Although the applicant did not receive preference for this criterion

because it has not clearly demonstrated there are populations of

unmet need, the applicant discussed populations it believes to be

underserved.

Compassionate Care Hospice of Florida states it is committed to

meeting the needs of all its patients and their families in need of

end-of-life in Miami-Dade and Monroe Counties. The applicant

states that it is going to admit patients of all ages and diagnoses.

According to the applicant specific underserved patient

populations include terminally ill residents in small ALFs, the four

age/diagnosis cohorts and terminally-ill Hispanic residents.

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

provide the inpatient care component of the hospice program through contractual arrangements with existing health care facilities, unless the applicant demonstrates a more cost-efficient alternative.

Compassionate Care Hospice of Florida intends to have contractual

agreements with nursing homes and hospitals, as well as other

healthcare providers designed to meet patient needs in Miami-

Dade and Monroe Counties. The applicant states that by

partnering with hospitals and nursing homes to provide hospice

patient care, it will fulfill its goal to expand awareness and

utilization of hospice. The applicant received letters of support and


18

agreements for contractual inpatient hospice services from the

following Service Area 11 hospitals and SNFs: Palmetto General

Hospital; Lower Keys Medical Center, Fishermen‟s Hospital;

Kindred Hospital South Florida Coral Gables; Larkin Community

Hospital; The Nursing Center at Mercy; Harmony Health Center;

Fair Havens Center; Oceanside Extended Care Center; Claridge

House Nursing & Rehabilitation Center; North Beach

Rehabilitation Center; Hampton Court Nursing & Rehabilitation

Center and Homestead Manor.

(3) Preference shall be given to an applicant who has a

commitment to serve patients who do not have primary caregivers at home; the homeless; and patients with AIDS.

Compassionate Care Hospice of Florida is committed to serving all

patients including those who do not have primary caregivers at

home, the homeless and patients with AIDS in Service Area 11.

The applicant states that its commitment is evidenced by its

history of serving these patients in other markets. The applicant

states that in 2009, 8.5 percent of all Compassionate Care Hospice

patients “lived alone” without a caregiver and 3.3 percent “lived

with a compromised caregiver”. In the case that the patient is not

able to care for him/herself and has no caregiver support group,

Compassionate Care may recommend placement in an assisted

living facility or nursing home, in which the hospice program will

be able to provide residential care. The applicant states that its

social workers will assist patients without financial resources to

obtain residential care in a hospice unit within an ALF or nursing

home, as determined by their medical condition. The applicant

states that typically if a patient in need of hospice care is

homeless, Compassionate Care will place the patient in an

inpatient unit and assist in applying for Medicaid; once the patient

qualifies, he/she is placed in a long-term care environment where

the patient can begin or continue hospice care.

However, the process of qualifying the homeless for Medicaid can

be difficult. One way in which the homeless can receive Medicaid

is by qualifying for Supplemental Security Income (SSI) benefits

through social security. Once becoming eligible for SSI, Medicaid

coverage is a benefit of the program. In most cases, the hospital

will initiate the process of applying for SSI and Medicaid in order to

receive payment for services. The homeless can receive SSI for six

months out of every nine months they stay in a public (government

run) emergency shelter. There is no time limit on getting SSI in a

private shelter.


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(4) In the case of proposals for a hospice service area comprised

of three or more counties; preference shall be given to an applicant who has a commitment to establish a physical presence in an underserved county or counties.

The applicant has conditioned approval of this application on the

provision its main office will be located in Hialeah, Miami-Dade

County. The applicant states that its second office location will be

in Marathon, Monroe County and will open during the first year of

operation.

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

The applicant states it offers a host of special programs and

services that are not specifically covered by private insurance,

Medicaid or Medicare. The applicant commits to provide the

following non-core services:

Pathways to Compassion - a palliative care program whose

mission is to prevent and relieve suffering and to support the

highest quality of life for patients and families. The program is

not the same as hospice care nor is its patients counted as

hospice patients in either state or federal reports. Palliative

care may be provided at any time during a person‟s illness or

debilitating condition.

Complementary Care Program - services offered in this program

are massage therapy, music therapy, energetic care, sacred

spaces, guided imagery, reminiscence therapy, and pet therapy.

Transitions - a community service program, designed to

enhance the quality of life for individuals and their families

facing life-limiting illnesses. Services include emotional

support, education, and practical assistance such as running

errands, performing house chores and food preparation.

Transitions is a free service provided to eligible

residents/patients and is funded by Compassionate Care

Hospice and community donations.


20

Jewish Hospice Program – Compassionate Care provides and

coordinates resources and services that meet the needs of the

Jewish Community surrounding loss, life‟s changes, terminal

illness, dying and grief.

Hispanic Hospice Program – Compassionate Care develops all

Hispanic/Spanish speaking interdisciplinary teams to serve the

needs of these patients. All patient informational brochures are

available in Spanish and all team members are bilingual,

including chaplains, nurses, social workers and others. Staff is

trained on cultural sensitivities and recognizes important

Hispanic related dates and events.

Compassionate Care 4 Kids – services are provided in a team

approach to patient care strengthened for Compassionate Care

partnerships with local children‟s hospitals.

Life Enhancement Specialists – are paid employees at

Compassionate Care who provide recreational activities for

socially isolated patients. The life enhancement specialist

focuses on enhancing the patient‟s quality of life by carrying out

various activities such as painting the patient‟s nails, playing

music, conversing with the patient and keeping this person

company. Schedule 6 provides for one FTE life enhancement

specialist.

Homemaker – full-time paid employees whose role is to carry

out day to day tasks on behalf of the patient and/or patient‟s

family to maintain the home. Homemakers are not licensed

professionals and therefore they cannot do all activities of daily

living such as bathing the patient. Schedule 6A includes one

homemaker FTE in year one and two homemaker FTEs in year

two.

Cardiac Connections - a care model developed to meet the

unique needs of patients with advanced cardiac disease and

congestive heart failure. Treatment will greatly reduce or

eliminate visits to the emergency room and hospitalization.

Promise Program – meets the requirements of needy

populations. Compassionate Care provides a supportive

network of medical, nursing, and psychosocial interventions for

patients who may be considering stopping dialysis treatments.


21

First Night at Home – program is designed to ensure new

hospice patients receive a little extra support the first few days

on service. Hospice aides are staffed for evening or “off hour”

shifts. Weekend personal care support is readily available to all

patients.

Veterans Outreach – will be implemented to meet the end-of-life

needs of this patient population by assisting veterans in

accessing available services and supports offered to veterans.

Community Outreach – reaches out to local schools and

supports children experiencing the death of a loved one.

Compassionate Care hospice teams will participate and sponsor

community toy and food drives around the holidays.

Compassionate Care will also partner with local hospitals and

healthcare organizations to reach beyond hospice and focus on

wellness and patient education; and attend and/or host

community health and wellness fairs and other events.

Volunteer Services – trained volunteers will be used to provide

administrative support and direct patient care. Volunteer

services will be based on patient need and requests as assessed

by the volunteer coordinator

Bereavement Services – after a patient has died, the team will

keep in contact with the family on a regular basis for at least 13

months after the death of a love done. The team may provide

memorial services in long-term care facilities and assisted living

facilities.

Rainbows – is a bereavement support program for children who

are experiencing grief through a death or divorce in the family.

Comfort Corners – is a program in which Compassionate Care

sponsors designated areas within a long-term care facility and

decorates the area to resemble a warm, home-like environment

for hospice patients and their families.


22

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

following general provisions and review criteria to be considered in reviewing hospice programs. (1) Required Program Description (Rule 59C-1.0355(6), Florida

Administrative Code): An applicant for a new hospice program shall provide a detailed program description in its certificate of need application, including:

(a) Proposed staffing, including use of volunteers.

The following is the proposed staffing for years one and two

of operation:

Position Average Number of FTE Year One

Average Number of FTE Year Two

Administrator 1.00 1.00

Professional Relations Coordinator 1.50 1.50

Secretary 1.00 2.00

Community Liaison 1.00 1.50

Clerk for Monroe Office 1.00 1.00

Medical Director 0.20 0.60

Registered Nurse 2.00 10.00

Per Diem Registered Nurses 0.30 2.00

Licensed Nurse Practitioners 1.00 1.60

Per Diem Lic‟d Nurse Practitioners 1.00 1.60

Nurses Aides 5.00 19.00

Per Diem Nurses Aides 0.40 1.60

Homemaker 1.00 2.00

Life Enhancement Specialist 1.00 1.00

Continuous Care Per Diem LPN 0.12 0.56

Continuous Care Per Diem Aide 0.12 0.56

Music Therapist 0.20 0.50

Massage Therapist 0.20 0.50

Dietary Services 0.20 0.50

Social Worker 1.00 3.00

Volunteer Coordinator 1.00 1.00

Chaplain 0.50 1.50

Total 20.74 54.92 Source: CON Application #10091, Schedule 6A.


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(b) Expected sources of patient referrals.

The applicant states that referrals will come from area

physicians, hospitals, nursing homes and other healthcare

providers, family members and patients themselves.

Compassionate Care states it will develop programs and

services geared toward Service Area 11 referral sources. The

applicant has letters of support from Service Area 11

hospitals, skilled nursing homes, assisted living facilities,

physicians and community organizations.

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

including Medicare, Medicaid, private insurance, self-pay, and indigent care patients for the first two years of operation.

The applicant provided the following table illustrating its

projected number of admissions by payer type for the first

two years of operation.

Projected Number of Admissions by Payer Type

Compassionate Care Hospice of Florida, Inc. Service Area 11

Payer Type Year One Year Two

Medicare 206 570

Medicaid 7 18

Insurance 10 10

Self-Pay 0 0

Charity 3 8

Total 219* 606 Source: CON Application #10091, page 116. *Year One admissions calculate to 226.

The applicant projects Medicare will comprise 94.1 percent

of admissions, Medicaid 3.2 percent and charity 1.3 (1.36)

percent during the first two years of operations.

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

illness, for the first two years of operation.

Compassionate Care provided the following table illustrating

the projected number of admissions by type of terminal

illness for the first two years of operation.


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Projected number of Admissions by Diagnosis

For Compassionate Care Hospice of Florida, Inc. Service Area 11

Diagnosis Year One Year Two

Cancer 77 212

Cardiac 55 165

Respiratory 20 52

Renal Failure 10 30

HIV/AIDS 7 18

Other 50 129

Total 219 606 Source: CON Application #10091, page 117.

(e) Projected number of admissions, by two age groups,

under 65 and 65 or older, for the first two years of operation.

Compassionate Care provides the following table for the

projected number of admissions by age cohort.

Projected Admissions by Age Group for

Compassionate Care Hospice of Florida, Inc. Service Area 11

Under 65 Over 65 Total

Year One 33 186 219

Year Two 91 515 606 Source: CON Application #10082, page 80.

(f) Identification of the services that will be provided

directly by hospice staff and volunteers and those that will be provided through contractual arrangements.

The hospice care team shall directly provide the following

core services: nursing services, social work services, pastoral

or counseling services, dietary counseling, and bereavement

counseling services. Physician services may be provided by

the hospice directly or through contract. A hospice may also

use contracted staff if necessary to supplement hospice

employees in order to meet the needs of patients during

periods of peak patient loads or under extraordinary

circumstances.

The applicant states that core services will be provided by its

staff and volunteers. Compassionate Care will contract for

certain services as needed by the patients: durable medical

equipment, medical supplies, pharmaceuticals, physical

therapy, speech therapy, and occupational therapy. Non-

core services to be provided by Compassionate Care staff


25

versus contract include: massage therapy, music therapy,

energetic care, sacred spaces, guided imagery, reminiscence

therapy, pet therapy, aroma therapy, reflexology,

hypnotherapy, life enhancement services and homemaker

services.

(g) Proposed arrangements for providing inpatient care.

Compassionate Care intends to have contractual agreements

with nursing homes and hospitals designed to meet patients‟

needs in Service Area 11. The applicant expects to provide

106 inpatient days in year one and 488 inpatient days in

year two. The applicant has letters indicating willingness to

enter into agreements for inpatient hospice services from the

following Service Area 11 hospitals and SNFs: Palmetto

General Hospital; Lower Keys Medical Center, Fishermen‟s

Hospital; Kindred Hospital South Florida Coral Gables;

Larkin Community Hospital; The Nursing Center at Mercy;

Harmony Health Center; Fair Havens Center; Oceanside

Extended Care Center; Claridge House Nursing &

Rehabilitation Center; North Beach Rehabilitation Center;

Hampton Court Nursing & Rehabilitation Center and

Homestead Manor.

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

a freestanding inpatient facility, in hospitals, and in nursing homes.

Compassionate Care states it will not be constructing beds

and will contract for existing beds on an as needed basis; it

has no intent on increasing the total number of beds

available by facility (both hospital and nursing home).

Compassionate Care will use existing licensed beds as

patient needs warrant such services, increasing use for

hospice services as volumes and resulting needs expand.

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

The applicant states that one or more of the following clinical

criteria should be present for the hospice patient to be

considered appropriate for admission to general inpatient

care:


26

Pain:

o Investigation to define appropriate treatment

modality,

o Active treatment to control pain. May include

both change in medication and/or the routes of

administration,

o Titration of medications that cannot be done

safely at home,

o Need for advanced technology for analgesic

administration, i.e., IV narcotics.

Other Symptoms:

o Death is imminent and care requires ongoing

and frequent skilled nursing intervention,

o Symptoms fail to yield to home management or

furnishings the needed care at home is no longer

feasible,

o Severe anorexia/and or inability to swallow

necessitating alternative nutritional support,

o Fluctuating/deteriorating mental status

necessitating titration of medications, change in

environment or consultation and intervention by

psychologist or psychiatrist,

o Severe shortness of breath or respiratory

distress, intractable nausea or vomiting; open

lesions requiring frequent professional care;

unstable or multiple pathological fractures;

other complicated care that cannot be provided

in the home setting,

o Need for continued close monitoring of unstable

recurring medical conditions, i.e. hemorrhage,

severe anemia, severe hypertension, unstable

diabetes, recurrent seizures, etc.


27

Psychosocial Pathology: evaluation of disturbed mental

status; depression, anxiety in the extreme; and perception

and/or understanding that responds more positively in a

comprehensive care setting that is reassuring, safe

and/or therapeutic.

Compassionate Care states that it will provide respite care

when the patient‟s family/caregiver needs a short period of

relief. This will be offered on an “as needed” basis for a

maximum of five days per respite admission for a

Medicare/Medicaid patient. For patients covered by other

insurers, the duration may be approved for a longer period of

time.

(j) Provisions for serving persons without primary

caregivers at home.

Compassionate Care states it is committed to serving all

patients including those who do not have primary caregivers

at home. The applicant states it will admit patients to its

hospice service even if the patient does not have a caregiver

at home. The applicant states that during CY 2009, 8.5

percent of all its patients lived alone without a caregiver;

another 3.3 percent of its patients lived with a compromised

caregiver. The applicant states that if a patient does not

have a caregiver it may recommend placement in an assisted

living facility or nursing home, in which the hospice program

would provide residential care. The applicant states it will

assist patients without financial resources to obtain

residential care in a hospice unit within an ALF or nursing

home. The applicant also proposes to establish relationships

with area nursing homes and assisted living facilities, either

entering into per diem contracts or developing hospice units,

as the need arises.

(k) Arrangements for the provision of bereavement services.

Compassionate Care states its bereavement services policy is

to provide appropriate and coordinated bereavement services

and counseling to families and caregivers for at least 13

months following the death of the patient. In addition to

providing services to family and caregivers, services may be

provided to residents and staff of SNFs, ALFs and other

medical facilities as needed, for at least 13 months after the

patient‟s death. Bereavement services will begin with an


28

initial bereavement risk assessment to be completed by the

social worker, bereavement coordinator or designee within

five days of admission. The applicant states that the

bereavement coordinator may also provide supportive

counseling prior to the death of the patient. Within three to

five weeks after the patient‟s death, the bereavement follow

up assessment is completed by the bereavement counselor

following the patient‟s family/caregiver. The applicant states

it also provides bereavement support for children, called

Compassionate Courage. The children participate in art,

reading, poetry, writing exercises, group discussions,

drawings, memory collages, a “feeling toss” game and books.

(l) Proposed community education activities concerning

hospice programs.

The applicant states it will provide extensive community

education activities to increase hospice awareness and

utilization. Compassionate Care staffing include 1.5 FTE

professional relations coordinators in years one and two; 1.0

FTE community liaison in year one, and 1.5 FTE community

liaison in year two of operations. According to the applicant,

these individuals will be responsible for leading the Hispanic

outreach program, further developing relationships

throughout Miami-Dade and Monroe Counties. They will

also educate nursing home and assisted living facility

operators on the myths and benefits of hospice. The

applicant states it will host hospice educational events at

senior organizations, religious affiliated groups, veterans‟

organizations, health fairs and educate minority residents in

an effort to educate the community at large on the benefits of

holistic end-of-life care through hospice.

(m) Fundraising activities.

The applicant states that its parent, Compassionate Care

Hospice has a relationship with Compassionate Care Hospice

Foundation, an unrelated not for profit 501c3 organization,

whose mission is to provide the resources necessary to

support the extraordinary needs of hospice patients and

their families. The applicant states that Compassionate Care

Hospice does not actively raise funds from the community

but if an individual wants to make a charitable donation, the

applicant will direct those individuals to Compassionate Care

Hospice Foundation‟s website.


29

3. Statutory Review Criteria

a. Is need for the project evidenced by the availability, quality of care, accessibility and extent of utilization of existing health care facilities and health services in the applicant’s service area? ss. 408.035(1)(a) and (b), Florida Statutes.

The applicant is applying to establish a hospice program in Hospice

Service Area 11 in the absence of published numeric need.

The following chart illustrates the increase in hospice admissions for the

past five years. As shown below, admissions have increased from 7,813

in 2004 to 9,296 in 2009 with a decrease in admissions in 2005 and

2006.

Hospice Admissions for Service Area 11

Calendar Years 2005-2009 Calendar Year Admissions

2009

2008

2007

2006

2005

2004

9,296

8,519

8,112

7,804

7,605

7,813 Source: Agency for Health Care Administration Florida Need Projections for Hospice Programs, April 2005 - April 2010.

Compassionate Care states that it will enhance availability and

accessibility of hospice services for terminally-ill, underserved residents

of Service Area 11. These underserved groups include: terminally-ill

residents in small ALFs, Hispanic terminally-ill, non-cancer terminally-ill

under age 65 and 65 and older, and cancer terminally-ill under age 65

and 65 and older. The applicant states that there is consistently a gap in

projected hospice admissions published each and every batching cycle

which exceeds 3,000 admissions. Compassionate Care states to

maximize outreach to Hispanic residents of Miami-Dade County it will

place its main office in Hialeah, a densely populated Hispanic region of

the county. Compassionate Care states it will place a satellite office in

Marathon, Monroe County, which is located in the middle region of the

Florida Keys, during its first year of operation. Compassionate Care

states it will not impair volume at the existing hospices nor at the

approved but not yet operational HCR ManorCare. The applicant is

projecting year one admissions of 219 and year two admissions of 606;

both these, according to the applicant, are reasonable based on

Compassionate Care Hospice‟s experience in existing markets.

Compassionate Care states it will enhance access for those residing in


30

assisted living facilities, nursing home residents, and those who remain

at home but currently go without end-of-life care. The applicant states it

will implement a concentrated outreach program for ALFs and will visit

all licensed ALF providers, regardless of size, in the first year of

operation, and will provide educational information for each.

With regard to quality of care, the applicant states that its parent

Compassionate Care Hospice is in compliance with the conditions of

participation for hospice providers of services under the Health

Insurance for the Aged and Disabled Program (Title XVIII of the Social

Security Act) as well as the Medicaid Program. The applicant states that

it will provide all required core components of hospice care set forth by

Medicare conditions of participation as well as Florida hospice licensure

requirements. Compassionate Care has also conditioned the application

to specific operational conditions to demonstrate its quality care and

patient enhancement activities.

The applicant states that its parent company Compassionate Care

Hospice has the experience and expertise of developing several quality

hospice programs throughout the nation and with proven policies,

procedures and unique programming in place the applicant will be able

to provide care in the most efficient manner. The applicant states it will

contract for certain services such as durable medical equipment,

pharmaceuticals, medical supplies, recruitment of staff and ambulance

services. The applicant states it will ensure staff is educated in the

provision of appropriate, high quality effective and efficient services

enabling patients to receive the most appropriate pain and symptom

management to meet their needs.

Compassionate Care states it is committed to providing outstanding

quality programs in Service Area 11 by offering specific programs such as

pediatrics, specialized bereavement groups, veteran program, Jewish

hospice program to the extent there is demand, African-American

outreach, Hispanic hospice program, as well as Compassionate Care

specialized programming for specific diagnoses including cardiac and

renal disease. Compassionate Care will provide programmatic (clinical)

access to appropriate care, educate the constituent population, and

provide the highest quality of patient care possible.


31

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

Compassionate Care states it is committed to providing the highest

quality care possible to terminally ill patients and their families.

Compassionate Care Hospice is a newly formed entity. Although it has

received a certificate of need to provide services in Polk, Hardee, and

Highlands Counties, the program is not expected to be operational until

October 2010. As such, the applicant does not have an operating

licensure history in the State of Florida. The applicant states that

through its relationship with its parent company, Compassionate Care

Group, Ltd, which has a 17-year history of providing quality hospice care

it has access to a substantial body of knowledge, skills and experience in

establishing and operating hospice programs. Founded in 1993, the

applicant states has 24 hospice programs and 42 offices in 16 states:

New Jersey, Delaware, New York, Kansas, Massachusetts, Georgia,

Texas, South Dakota, Illinois, Virginia, Pennsylvania, Michigan, South

Carolina, Nebraska, Wisconsin and Minnesota.

The applicant asserts that it is committed to providing the highest

quality care possible to terminally ill patients and their families. The

applicant states that examples of its standard of high quality care are

demonstrated through its accreditation, staffing standards that surpass

NHPCO and national benchmarks, quality assessment and performance

improvement plan, patient/family satisfaction surveys, staff membership

in quality associations, in-service training, and staff continuing

education. The applicant has also conditioned to certain quality of care

measures to reflect its commitment to providing quality services.

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.

Th e a u d ited fin a n cia l s ta tem en ts of th e a pp lica n t were reviewed to a s s es s

th e fin a n cia l pos it ion a s of th e ba la n ce s h eet da te a n d th e fin a n cia l

s t ren gth of its opera t ion s for th e per iod p res en ted .

Th e a pp lica n t is a Flor ida for -p rofit corpora t ion a n d a developm en t s ta ge

com pa n y th a t wa s form ed on Sep tem ber 19 , 2007 for th e pu rpos e of

opera t in g a h os p ice in Flor ida , with n et a s s ets of $40 ,000 a n d $63 ,400 in

lia b ilit ies (du e to a ffilia te) for th e per iod en ded Decem ber 31 , 2009 . Th e

a u d it in d ica tes th a t th e a pp lica n t is econ om ica lly depen den t u pon th e

s tockh olders a n d a n a ffilia te to p rovide work in g ca p ita l. At th e da te of

th e a u d it , n o opera t in g res u lts were a va ila b le. With ou t res u lts from


32

opera t ion s , a n a n a lys is of th e s h or t a n d lon g-term s t ren gth of th e

a pp lica n t ca n n ot be m a de.

Capit al Re quire m e nt s :

Sch edu le 2 in d ica tes tota l ca p ita l p rojects of $433 ,700 wh ich con s is t of

th e CON s u b ject to th is review, CON #10082 for a h os p ice in Dis t r ict 8

a n d CON #10083 for a h os p ice in Dis t r ict 10 . In a dd it ion , th e a pp lica n t

will h a ve to fu n d th e p rojected yea r on e opera t in g los s of $505 ,331 a n d

th e com bin ed opera t in g los s es of CON #10082 ($520 ,170) a n d CON

#10083 ($441 ,644).

Available Capit al:

The applicant provided a letter from its parent corporation,

Compassionate Care Hospice Group, Ltd. (parent), which states the

parent will provide funding for the project. It should be noted that the

applicant included operating results of its parent. However, the

operating results provided by the parent are unaudited. An audit report

gives an independent opinion on whether or not the financial statements

are presented fairly in all material respects. Without an audit, we cannot

rely on the information presented in the parent‟s financial statements.

We did not find any other independent documentation (bank statements,

credit line agreements, and letters from banks or lenders) in the

application that would support the parent‟s ability to fund the project.

Therefore, funding for this project is in question. It should be noted that

this is consistent with our treatment of unaudited parent financial

statements for this applicant in CON #10061; however, in that case the

applicant provided additional independent documentation, namely a line

of credit agreement.


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Staffing: Position

Average Number of FTE Year One

Average Number of FTE Year Two

Administrator 1.00 1.00

Professional Relations Coordinator 1.50 1.50

Secretary 1.00 2.00

Community Liaison 1.00 1.50

Clerk for Monroe Office 1.00 1.00

Medical Director 0.20 0.60

Registered Nurse 2.00 10.00

Per Diem Registered Nurses 0.30 2.00

Licensed Nurse Practitioners 1.00 1.60

Per Diem Lic‟d Nurse Practitioners 1.00 1.60

Nurses Aides 5.00 19.00

Per Diem Nurses Aides 0.40 1.60

Homemaker 1.00 2.00

Life Enhancement Specialist 1.00 1.00

Continuous Care Per Diem LPN 0.12 0.56

Continuous Care Per Diem Aide 0.12 0.56

Music Therapist 0.20 0.50

Massage Therapist 0.20 0.50

Dietary Services 0.20 0.50

Social Worker 1.00 3.00

Volunteer Coordinator 1.00 1.00

Chaplain 0.50 1.50

Total 20.74 54.92 Source: CON Application #10091, pages 113-114.

Conclusion:

Funding for this project is in question.

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

cost-effectiveness? ss. 408.035(1) (e) and (g), Florida Statutes.

This application is for a new hospice program to be located in Service

Area 11 which currently has seven existing hospice programs. Therefore,

this project is offering a new choice of provider in the service area.

The impact of the price of services on consumer choice is limited to the

payer type. Most consumers do not pay directly for hospice services

rather they are covered by a third-party payer. The impact of price

competition would be limited to third-party payers that negotiate price

for services, namely managed care organizations. Therefore, price

competition is limited to the share of patient days that are under

managed care plans. The applicant is projecting 1.7 percent of its

patient days from managed care/commercial insurance payers with 97.0

percent of patient days expected to come from fixed price government

payer sources (Medicare and Medicaid), with the remaining 1.3 percent

as self-pay/charity.


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With the large majority of patient care being provided from fixed price

government payer sources, this project is not likely to have any

discernable positive impact on price-based competition to promote cost-

effectiveness. As providers offer new or enhanced services to patients

and families as a means to compete on quality measures, cost-

effectiveness would be impacted since the new or enhanced services

would be offered despite the large percentage of fixed priced government

payers. In other words, the potential exists for new or enhanced services

to be provided for the same federal and state dollars.

This project is not likely to result in price-based competition.

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

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

For year two of operations, the applicant projected the following

percentage of total patient days by group: Medicare at 94.0 percent,

Medicaid at 3.0 percent, self-pay/charity at 1.3 percent, and commercial

insurance at 1.7 percent.

The applicant indicated on Schedule 7 that the service it intends to

provide is routine home care, continuous home care, inpatient respite,

and general inpatient care, and for which the Department of Health and

Human Services sets rates. The federal rates were calculated for the

Miami-Dade County, Florida Wage Index for Medicare Hospice payments

of 1.0377 and inflated through March 2013. The average price

adjustment factor used was 2.7 percent per year based on the new CMS

Market Basket Price Index as published in the 1st Quarter 2010 Health

Care Cost Review.

Estimated patient days for each level of service from Schedule 7, year two

were multiplied by the calculated reimbursement rate for that service in

order to estimate the total revenue that would be generated by that

number of patient days. The results were then compared to the

applicant‟s estimated gross revenue. The results of the calculations are

summarized in the Table below.

The applicant calculated continuous care revenues based on 19.2 hours

of care rather than 24 hours. The applicant indicated that due to death

or other causes, some patients will not, however, receive 24 hours of

continuous care and will not, therefore, be eligible for reimbursement for

a given day. In our calculation, we made the same adjustment of a

partial 19.2 hour payment. Based on our calculation, the applicant‟s

projected gross revenue was 5.41 percent, or $277,499, less than the

calculated gross revenue. Based on the notes to the projections, it


35

appears the applicant only included one year of inflation where our

review included 2.5 years of inflation. When this difference is considered

the difference is not material. In any event, understating revenue is a

conservative assumption and therefore reasonable.

The applicant offered 12 conditions to its proposed hospice program.

Several of these conditions would likely have a financial impact on the

applicant, namely the nurse aide staffing ratio. It appears that the

applicant included sufficient FTEs to meet this condition.

Operating profits from this project are expected to increase from a loss of

$505,331 for year one to a profit of $502,743 for year two.

HOSPICE REVENUE TABLE

CON #10091 Compassionate Care Hospice of Florida, Inc.

Wage Index for Miami-Dade County(1.0377)

Wage Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $98.19 1.0377 $101.89 $44.72 $146.61

Continuous Home Care $573.11 1.0377 $594.72 $260.99 **$684.56

Inpatient Respite $80.02 1.0377 $83.04 $67.81 $150.85

General Inpatient $406.94 1.0377 $422.28 $228.80 $651.08

Payment Rate

Inflation Factor Year

Two

Inflation Adjusted Amount

Patient Days Year 2, March

31 -2013

Calculated Gross

Revenue

Routine Home Care $146.61 1.067 $156.49 31,912 $4,993,908

Continuous Home Care $684.56 1.067 $730.69 98 $71,607

Inpatient Respite $150.85 1.067 $161.01 33 $5,313

General Inpatient $651.08 1.067 $694.95 488 $339,135

Total 32,531 $5,409,964

From Schedule 7 $5,132,465

Difference

-$277,499

Percentage difference -5.41% **Continuous Home Care is calculated based on 19.2 hours of care rather than 24 hours.

Conclusion: Assuming the applicant will be able to acquire funding for

start-up and working capital, this project appears to be financially

feasible.


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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 and Ch. 59A-3 or 59A-4, Florida Administrative Code.

There are no construction costs and methods associated with the

proposal to establish a new hospice program.

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.

Compassionate Care Hospice of Florida states that its parent company

Compassionate Care Group, Ltd through its other Compassionate Care

Hospice subsidiaries has a history of providing health services to

Medicaid patients and the medically indigent. According to the

applicant, recent utilization reports from Compassionate Care Hospice in

calendar year 2009 show that collectively Compassionate Care Hospice

programs provided 23,447 Medicaid days representing 3.3 percent of

total patient days and 1.8 percent of total patient days to self-pay and

charity patients.

Schedule 7A shows 1.3 percent of total annual patient days for charity

care in years one and two of operations. Compassionate Care‟s patient

day Medicaid percentage is projected to be 3.0 percent for year one and

two of operations. F. SUMMARY

Compassionate Care Hospice of Florida, Inc. is applying to establish a

hospice program in Hospice Service Area 11 (Miami-Dade and Monroe

Counties) in the absence of published numeric need. Compassionate

Care contends special circumstances exist to support the approval of the

project.

The applicant is proposing total project costs of $141,950 with year one

operating costs of $1,527,651 and year two costs of $4,561,439.

Compassionate Care proposes 12 conditions (see pages 3-5).


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Need/Access:

Service Area 11 presently has seven licensed hospice programs. HCR

Manor Care Services of Florida II, Inc. has CON #10043 approved but yet

to be licensed to establish a hospice program in Service Area 11. The

Agency shall not normally approve another hospice program for any

service area that has an approved hospice program that is not yet

licensed.

The applicant identified the following not normal and special

circumstances within Service Area 11:

Hospice Service Area 11 has a consistent gap in admissions exceeding

3,000 over the past eight batching cycles;

Terminally-ill patients residing in small assisted living facilities have

low hospice penetration rates due to lack of education and outreach

by existing providers;

Hispanics of all age/diagnosis categories have lower utilization of

hospice services than non-Hispanics due to limited knowledge of

hospice programs and goals, and negative cultural attitudes and

beliefs surrounding end-of-life care;

Terminally-ill non-cancer and terminally-ill cancer patients have lower

hospice penetration rates than patients throughout the State of

Florida.

The applicant has letters of support from Hospice Service Area 11

hospitals, skilled nursing facilities, assisted living facilities, physicians,

and community organizations. The applicant‟s support letters do not

document that hospice services are not available or accessible to any

specific population in the service area. The applicant has letters of

support from representatives of five hospitals and 10 nursing homes that

state interest in contracting for inpatient hospice services. The applicant

forecasts 219 admissions in year one and 606 admissions in year two of

operations.

Quality of Care:

The applicant offered evidence of its ability to provide quality care based

on its hospice programs in other states. Compassionate Care has

received a certificate of need to establish a hospice program in Polk,

Hardee, and Highlands Counties, Service Area 6B. The program is not

expected to be operational until October 2010.


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Financial Feasibility/Availability of Funds:

Without results from operations, an analysis of the short and long-term

strength of the applicant cannot be made. There is no audit of the

parent or independent documentation that supports the parent‟s ability

to fund the project. Funding for this project is in question. However,

assuming the applicant will be able to acquire funding for start-up and

working capital, this project appears to be financially feasible. G. RECOMMENDATION

Deny CON #10091.


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AUTHORIZATION FOR AGENCY ACTION

Authorized representatives of the Agency for Health Care Administration

adopted the recommendation contained herein and released the State Agency

Action Report.

DATE:

James B. McLemore Health Services and Facilities Consultant Supervisor Certificate of Need

Jeffrey N. Gregg Chief, Bureau of Health Facility Regulation

STATE AGENCY ACTION REPORTahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10091.pdf · assisted living facility), and South Hialeah Manor, a 67-bed assisted living facility, and executive

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