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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
2
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,
CON Action Number: 10091
3
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.
CON Action Number: 10091
4
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.
Compliance will be measured by a signed declaratory statement
submitted to the Agency.
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.
Compliance will be measured by a signed declaratory statement
submitted to the Agency.
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.
CON Action Number: 10091
5
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.
CON Action Number: 10091
6
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.
CON Action Number: 10091
7
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.
CON Action Number: 10091
8
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
CON Action Number: 10091
9
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
CON Action Number: 10091
10
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
CON Action Number: 10091
11
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
CON Action Number: 10091
12
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
3
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.
CON Action Number: 10091
13
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.
CON Action Number: 10091
14
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
Hospice Penetration Rate 21.8% 64.9% 53.9%
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.
CON Action Number: 10091
15
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.
CON Action Number: 10091
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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
Hospice Penetration Rate 72.7% 87.9% 83.4%
Florida
Hospice Admissions 10,494 27,513 38,007
2007 Resident Deaths 11,132 28,634 39,766
Hospice Penetration Rate 94.3% 96.1% 95.6%
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.
CON Action Number: 10091
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
CON Action Number: 10091
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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.
CON Action Number: 10091
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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.
CON Action Number: 10091
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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.
CON Action Number: 10091
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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.
CON Action Number: 10091
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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.
CON Action Number: 10091
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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.
CON Action Number: 10091
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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
CON Action Number: 10091
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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:
CON Action Number: 10091
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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.
CON Action Number: 10091
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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
CON Action Number: 10091
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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.
CON Action Number: 10091
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3. Statutory Review Criteria
a. Is need for the project evidenced by the availability, quality of care, accessibility and extent of utilization of existing health care facilities and health services in the applicant’s service area? ss. 408.035(1)(a) and (b), Florida Statutes.
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
CON Action Number: 10091
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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.
CON Action Number: 10091
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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
CON Action Number: 10091
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.
CON Action Number: 10091
33
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.
CON Action Number: 10091
34
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
CON Action Number: 10091
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.
CON Action Number: 10091
36
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).
CON Action Number: 10091
37
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.
CON Action Number: 10091
38
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.
CON Action Number: 10091
39
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