state agency action report - agency for health care administration

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Haven Behavioral Health Services of Florida, LLC/CON #10103 652 West Iris Drive Nashville, Tennessee 37204

Authorized Representative: Kirk McConnell, Esquire Vice President and General Counsel (615) 250-9500

2. Service District/Subdistrict

District 5 (Pasco and Pinellas Counties)

B. PUBLIC HEARING

A public hearing was not held or requested regarding the applicant’s proposal to establish a 40-bed adult inpatient psychiatric hospital in Pinellas County.

Letters of Support

The applicant submitted 24 letters of support for the project from representatives of 13 District 5 skilled nursing facilities (CON application

#10103, Attachment E – Letters of Support). Twenty were signed during August 24 - 27, 2010. Four were signed but not dated. The letters are

brief and essentially state that there is a need for a specialized behavioral service specifically dedicated to the geriatric population. Multiple support letters were from Countryside Rehab and Health Care Center

(four), Edinborough Healthcare Center (four), East Bay Rehabilitation Center (three), Cross Terrace Rehabilitation Center (two), The Oaks of Clearwater (two), and The Allegro at College Harbor (two). The following

CON Action Number: 10103

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facilities each submitted a support letter for the project: Alpine Health and Rehabilitation Center, Egret Cove Center, Palm Garden of Pinellas,

HarbourWood Health & Rehab Center, Shore Acres Rehabilitation and Health Center, Tierra Pines Center and Westchester Gardens

Rehabilitation and Care Center. The letters are brief and essentially state that there is a need for a

specialized behavioral service specifically dedicated to the geriatric population. Excerpts of these include:

Steve Kelly, Administrator of The Allegro at College Harbor who states:

Stephen Jones, Administrator, Palm Garden of Pinellas writes:

Dona Conde, RN, Director of Nursing at Cross Terrace Rehabilitation Center states:

Several SNF administrators state that the “elderly are frail, and can become quickly confused. Their own special unit should help to relieve

them from confusion and being frightened” and that they are pleased Haven will not place their patients in a general population of an acute

care hospital


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Letters of Opposition

Karen Putnal of Parker, Hudson, Rainer & Dobbs, LLP, Attorneys at Law, on behalf of Morton Plant Hospital Association, Inc., stated three reasons

that Morton Plant opposes the project. These are:

the lack of numeric, geographic, financial or programmatic need for

an additional adult inpatient psychiatric hospital in District 5,

the existence of available and accessible high quality adult inpatient

psychiatric services in the District; and

the anticipated adverse impact on Morton Plant Hospital’s existing

adult inpatient psychiatric programs.

Ms. Putnal commented that Morton Plant Hospital has demonstrated a long-standing commitment to serve all residents of the community, regardless of ability to pay and has consistently promoted community

access through its broad range of adult inpatient psychiatric services. Ms. Putnal also indicated the applicant’s proposal would not

meaningfully enhance access to the community, and in particular would not enhance access for Medicaid beneficiaries, the uninsured or underinsured.

Lauren Borowsky, Consultant, National Healthcare Associates, Inc. on

behalf of Windmoor Healthcare of Clearwater submitted a 13-page analysis in opposition to the project. Ms. Borowsky provided a nine-point opposition statement (see below).

• In CY 2009, District 5 was licensed for 261 adult psychiatric beds.

During 2010, 17 new beds were added at Largo Medical Center –

Indian Rocks (Pinellas County) and 56 were licensed at the new freestanding Morton Plant North Bay Recovery Center in Pasco

County. District 5 is presently licensed for 334 beds.

• There are 77 approved beds for District 5, 42 beds at Windmoor

(Pinellas County) and 35 at Ten Broeck Hospital (Pasco County) Existing, newly licensed and approved beds are dispersed through

the two-county area, with 411 adult inpatient psychiatric beds in District 5.

• Windmoor Healthcare of Clearwater has plans to re-open a 20-bed adult psychiatric unit and has three voluntarily closed units that could be easily renovated. This would be a less costly alternative than

the proposed project, if demand was ever achieved. However, it is not anticipated that there will be such demand for the planning horizon

and thereafter given the surplus of beds.


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• Windmoor notes that District 5’s CY 2009’s occupancy with 261 beds was 78.9 percent. With the addition of the 77 more beds, the rate

would be 63.7 percent. Once Windmoor Healthcare of Clearwater adds 42 beds and Ten Broeck Hospital’s (35 beds) adult inpatient

psychiatric projects are completed, a district-wide occupancy rate of 50 percent is anticipated.

• Community Hospital (CON #10074) has approval to maintain its 46 beds at its existing location rather than move them to its replacement hospital. This will result in a freestanding 46-bed adult inpatient

psychiatric hospital that could renovate existing space to add beds as needed without a CON application.

• Given the newly licensed beds, current approved inventory, and ability

for both Community Hospital and Windmoor to expand in the future

in existing space, which would be less costly, there is no need to approve Haven.

• As a freestanding psychiatric hospital, Haven Behavioral Hospital of

Largo would be precluded from participating in the Medicaid program.

Windmoor Healthcare of Clearwater, as a freestanding psychiatric hospital in Pinellas County, also adheres to this same exclusion. So, Haven would be vying for identical patients and thus adversely

impacting an already limited patient pool. This would cause duplication of already available services, especially considering

Windmoor is undergoing renovations to add 42 adult inpatient psychiatric beds, which are more than the entire 40-bed hospital proposed by the applicant.

• Haven would adversely impact Windmoor Healthcare and other

District 5 psychiatric providers by drawing upon an already limited

pool of qualified mental health nurses and technicians. This concern is stated in the three form letters from practicing psychiatrists (listed

below).

• F. Kevin Butler, M.D., Behavioral Healthcare Options; Dinar Sajan,

M.D., Health and Psychiatrist Consultants, LLC; and Theodore J. Machler, M.D., Windmoor Healthcare of Clearwater opposition letters

state “I know first-hand that there are high quality mental health inpatient services with beds readily available in both Pasco and Pinellas Counties. I have not experienced any difficulties in trying to

find available and accessible beds for my patients…”.


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Ms. Borowsky concludes that Haven’s project would be a duplication of available and accessible services. District 5 has seen an influx of 73

beds in 2010 and is set to gain 77 more in the near future. She states that “for health planning to be effective, the market needs to absorb all

150 beds before yet another freestanding psychiatric hospital is approved”.

Stephen Ecenia of Rutledge, Ecenia & Purnell, P.A., Attorneys and Counselors at Law, on behalf of Largo Medical Center, submitted a 24-page letter of opposition to the project. The opposition letter was

prepared by Sullivan Consulting Group, Inc. Largo Medical Center opposes the project because:

approval would be inconsistent with applicable review criteria with no

need for the project, especially considering a projected average daily census (ADC) of 208 patients in the area by 2015 and an inventory of 411 adult psychiatric beds.

existing and approved providers in the district (including Morton Plant North Bay and Ten Broeck Tampa in Wesley Chapel) have the capacity

to support any increase in demand.

an expected increase in licensed beds in the area will likely reduce

occupancy rates at existing facilities.

a lack of need is even more apparent in Pinellas County where the

applicant proposes to locate its project. Largo states that the existing beds are concentrated in central Pinellas County. Pinellas residents

have historically had greater access to adult psychiatric services and the availability of services will increase with opening of the 42 beds at Windmoor.

the project will not improve financial access to adult psychiatric services, especially considering that as a freestanding psychiatric

facility, Haven will be unable to receive Medicaid reimbursement and will necessarily seek to capture the commercially insured and

Medicare populations who do not have problems accessing psychiatric services.

the project would adversely impact Largo Medical Center-Indian

Rocks and other existing and approved facilities in District 5, with no counterbalancing benefit to the health care system.


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C. PROJECT SUMMARY

Haven Behavioral Health Services of Florida, LLC (CON #10103)

proposes to establish a new 40-bed adult inpatient psychiatric hospital on leased property at 1551 West Bay Drive, in the City of Largo, Pinellas County, Florida1. Haven indicates that the facility will do business as

Haven Behavioral Hospital of Largo and will initiate service in April 2012. The applicant states the service area for the proposed hospital will be Pinellas County, with a focus on six zip codes adjacent to the proposed

site.

Haven Behavioral Services of Florida, LLC is a newly created, wholly-owned subsidiary of Haven Behavioral Healthcare, Inc., ultimately parented by Haven Behavioral Healthcare Holdings, LLC, a for-profit

corporation. Haven owns and operates nine psychiatric inpatient facilities in six states, including two dedicated geriatric psychiatric

hospitals. Total project cost is $2,579,307. The total project cost includes:

building, equipment, project development and start-up costs. The project involves 20,380 gross square feet (GSF) of renovation at $1,365,253 in construction cost.

The applicant proposes the following conditions:

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

inpatient treatment for a behavioral condition.

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

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

first month after discharge to assist post hospitalization care givers with maintaining the gains achieved during hospitalization.

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

medication management of geriatric psychiatric patients.

4. Haven will host separate annual mental health conferences for

health care professionals and the general community.

1 The applicant does not offer a zip code, however MapQuest indicates that for 1551 West Bay Drive,

Largo, Florida, the zip code is 33770.


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5. Haven will provide an annual report to the Agency summarizing the MS-DRGs and psychiatric diagnoses of patients discharged

from the facility in the previous 12-month period.

6. Haven will create and maintain a report indicating dates of discharge and follow up on patients post-discharge and submit the report to the Agency annually.

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

pharmacist working at the proposed facility annually.

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

provided for health care professionals and community to the Agency each year. The Agency will be notified of conferences in advance of the meeting date and will be invited to attend.

The applicant’s proposed conditions (one through four) are as it stated. Conditions five through eight were described as “monitoring conditions” by the applicant. Should the project be approved, the applicant’s proposed conditions would be reported in the annual condition compliance report as required by Rule 59C-1.013 (3) Florida Administrative Code.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review criteria found in Sections 408.035 and 408.037, Florida Statutes, and rules of the State of Florida, 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 and data

provided in the application, and independent information gathered by the reviewer.

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

project in the same district (subdistrict), applications are comparatively reviewed to determine which applicant best meets the review criteria.


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

amendments once an application has been deemed complete. The burden of proof to entitlement of a certificate rests with the applicant.

As such, the applicant is responsible for the representations in the application. This is attested to as part of the application in the Certification of the Applicant.

As part of the fact-finding, the consultant, Steve Love, analyzed the application in its entirety with consultation from the economic analyst,

Felton Bradley, who evaluated the financial data, and the architect, Scott Waltz, who evaluated the architectural and the schematic drawings as

part of the application.

E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicate the level of conformity of the proposed project with the review criteria and application content requirements found in Sections 408.035 and 408.037, Florida Statutes, and applicable rules of

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

1. Fixed Need Pool

a. Does the project proposed respond to need as published by a fixed need pool? Or does the project proposed seek beds or services in excess of the fixed need pool? ss. 408.035 (1)(a), Florida Statutes,

Rules 59C-1.008(2) and 59C-1.040(4) Florida Administrative Code. In Volume 36, Number 29, dated July 23, 2010 of the Florida

Administrative Weekly, a fixed need pool of zero beds was published for adult inpatient psychiatric beds in District 5 for the January 2016

planning horizon. The applicant is not responding to a fixed need pool but what the applicant considers “not normal” circumstances.

District 5 had 261 licensed adult inpatient psychiatric beds, as of December 31, 2009. The chart below shows District 5’s adult inpatient

psychiatric beds utilization during the 12-month period ending December 31, 2009.


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District 5

Adult Inpatient Psychiatric Bed Utilization

January 2009 – December 2009 Facility Class

Type

County Licensed

Beds Patient Days

Occupancy

Community Hospital Class 1 Pasco 46 14,605 88.98%

Florida Hospital Zephyrhills Class 1 Pasco 15 3,344 68.61%

Largo Medical Center-Indian Rocks Class 1 Pinellas 18 5,822 90.47%

Morton Plant Hospital Class 1 Pinellas 54 13,078 71.05%

St. Anthony’s Hospital Class 1 Pinellas 50 14,848 84.13%

Windmoor Healthcare of Clearwater Class 3 Pinellas 78 19,655 73.62%

District 5 Total

261

71,352

78.86%

Source: Florida Hospital Bed Need Projections and Service Utilizations by District, July 2010

Batching Cycle.

As of July 23, 2010, District 5 had 278 licensed and 133 approved adult

inpatient psychiatric beds. Largo Medical Center Indian Rocks licensed 17 adult psychiatric beds effective February 19, 2010. The approved beds are listed below:

District 5

CON Approved Adult Inpatient Psychiatric Beds Facility/County CON/Exemption/Notification # # Beds

Ten Broeck Tampa, Inc. /Pasco CON #10010 35

Morton Plant Hospital Association, Inc./Pinellas E#1000008 56

Windmoor Healthcare of Clearwater/Pinellas

E#1000002 (20 beds)

N#1000007 (22 beds)

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District 5 Total 133 Source: Florida Hospital Bed Need Projections and Service Utilizations by District, July 2010

Batching Cycle.

Note: Morton Plant licensed the 56 adult psychiatric beds (Ex. #1000008) at Morton Plant North Bay Recovery Center effective August 18, 2010.

The following is a map of District 5’s licensed and CON approved adult inpatient psychiatric facilities and the applicant’s proposed Pinellas

County (CON #10103) site.


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District 5 Licensed and CON Approved

Adult Inpatient Psychiatric Facilities and

Haven Behavioral Services of Florida, LLC (CON #10103)

Source: MapPoint 2006.

Below are District 5 population projections for July 1, 2009 and the

January 1, 2016 planning horizon.


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Population Estimates for District 5

(Population Age 18 and Over and Population Age 65 and Over)

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

County

Population

Age 18 & Over

July 2009

Population Age 18 &

Over January

2016

Percent Change

Population Age 65 &

Over July 2009

Population Age 65 &

Over January

2016

Percent Change

Pasco 347,491 386,773 11.30% 103,924 122,286 17.67%

Pinellas 759,706 768,427 1.15% 201,916 226,293 12.07%

District Total 1,107,197 1,155,200 4.34% 305,840 348,579 13.97%

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

3,302,610

3,990,155

20.82%

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

As shown above, District 5’s population age 18 and over and population age 65 and over are projected to have lower percentage growth from July 2006 to January 2016 than the state. Pinellas County’s population age

18 and over and population age 65 and over are both projected to increase at a lower percentage rate than Pasco County’s.

b. “Not Normal” Circumstances.

Haven states it is applying under “not normal” circumstances for the establishment of a 40-bed adult inpatient psychiatric hospital in Pinellas County, District 5, with a dedicated geriatric focus, to provide care to an

underserved population. Haven states the need for geriatric psychiatric services is not being met by existing providers in District 5. The

applicant states several “not normal” circumstances that justify the project. These areas are described below, by the applicant.

The Elderly in District 5 and the Service Area Receive Disproportionately Less Inpatient Psychiatric Care than Other Adults and the Statewide Rate

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

same level of psychiatric care as other adults. The applicant states a disproportionately lower use of inpatient services is received by the elderly population. According to the applicant, in District 5 in 2009, the

elderly represented 13.5 percent of psychiatric discharges compared to 21.6 percent of the resident population. The applicant also states that

service area discharge use rates for elderly age 65-74 and elderly 75 and over were “significantly below”2 those for adults under age 65. Haven contends that the small proportion of elderly patients at psychiatric

facilities is more evidence that the elderly are underserved. According to the applicant, statewide, 87 percent of adult psychiatric patients were

2 CON application #10103, page #9.


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under the age of 65. In District 5, 86 percent of adult psychiatric patients were under 65. Haven states in the absence of dedicated

geriatric psychiatric beds, the elderly are unlikely to receive treatment even with exacerbation of an underlying behavioral condition.

Haven indicates that its primary service area will be Pinellas County and in zip codes 33564, 33570, 33571, 33574, 33576, and 33578 (CON

application #10103, page 21) and refers the reviewer to Exhibit 1. There is no Exhibit 1; however, Exhibit 2 is titled “Service Area Map with Providers” and does not show the applicant’s proposed location. Further,

notes to the applicant’s Table 4 on page #23 indicate a primary service area defined as zip codes 33764, 33670, 33671, 33674, 33576 and

33578. The applicant is not clear on its proposed zip code service area. However, we do have the facility’s address and based on the address of the proposed facility which is in zip code 33770, the six adjacent zip

codes are 33774, 33778, 33773, 33771, 33764, and 33756.3 CON application #10103, page #1 indicates a service area of Pinellas County,

with no specified zip codes. The applicant’s location supports the zip codes found in the reviewer’s zip code look-up.

Mental Health Conditions in Older Adults Not Addressed Haven asserts one of the most important reasons that the elderly are less

likely to receive psychiatric care is that mental health conditions of older adults are not addressed. The applicant explains that in normal aging,

important aspects of mental health include stable intellectual functioning, capacity for change, and productive engagement with life. However, a “substantial proportion” of the population 55 and older –

almost 20 percent-experience specific mental disorders that are not part of normal aging. Older adults experience many of the same mental disorders as other adults; however, the prevalence, nature, and course of

each disorder may be very different. Haven states that unaddressed in older adults are depression, Alzheimer’s disease, alcohol and drug

misuse and abuse, anxiety, late-life schizophrenia, and other conditions that can be severely impairing or even fatal. The applicant concludes that in general, assessment and diagnosis of mental disorders in older

adults can be challenging by virtue of several distinctive characteristics which the project is designed to solve.

Service Area Nursing Home Residents Have Unaddressed Behavioral Health Disorders

The applicant states that nursing homes have become the refuge of the elderly with psychiatric conditions. For instance, the applicant states

depression prolongs nursing home care and increases costs in acute and

3 USPS zip code Lookup & Boundary Map at http://www.usnaguide.com/zip.htm.

http://www.usnaguide.com/zip.htm


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rehabilitative services while also increasing the risk of re-hospitalization among elderly persons. According to the applicant, the nine-page 2004

National Nursing Home Survey (NNHS) public use files indicated that 6.1 percent of geriatric nursing home patients had a psychiatric principal

diagnosis and another 41.5 percent had a secondary psychiatric diagnosis. Despite what the applicant considers a prevalence of psychiatric conditions among nursing home residents, the applicant

states the mental health status of these patients may not be re-evaluated when a major change in health status or exacerbation of a mental condition occurs. In addition, even if a problem needing treatment is

identified, gaining placement in a specialized psychiatric facility can be challenging.

Haven states elderly mental health patients require specialized care, staff training, and placement resources that are not generally available at

most behavioral health providers. The applicant identifies the following as issues of elderly patients with regard to specialized care:

1. Incompatibility of elderly and non-elderly psychiatric patients

Adult patients under age 65 are more likely to be hospitalized for psychoses, usually schizophrenia and bipolar mood

disorders, than are geriatric patients, who are equally likely to be diagnosed with degenerative nervous system disorders (such as Parkinson’s disease, Huntington’s disease, or Alzheimer’s

disease) or organic brain disturbances.

The psychotic non-elderly adult patient has few boundaries and may display inappropriate behaviors. These patients may not

be able to tolerate the general intrusiveness of geriatric patients with dementia, who are confused and may be frail.

Geriatric patients require different approaches to assessment, diagnosis, and treatment modalities than non-elderly adults.

2. Medication Management

Another significant commitment required in providing care to

geriatric psychiatric patients is management of medications. Geriatric patients typically take several prescriptions per day, with an average of 9.5 prescriptions per patient in the NNHS.

This increases the probability of adverse drug effects and suboptimal care.

The aging process leads to changes in the way medications are tolerated. Geriatric psychiatric care includes evaluation and

effectiveness of the patient medications.


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3. Specialized discharge planning and aftercare needs

Haven’s specialized geriatric psychiatric care is focused on

coordination of care with nursing homes and assisted living facilities and the patient’s family. By specializing in only

geriatric care, Haven personnel are able to work closely with a smaller number of providers.

4. Fall risk and patient safety

Patient falls are a much greater safety concern in the elderly

population. In the 2004 NNHS (mentioned previously), residents with a principle or secondary mental health diagnosis

reported a significant number of falls. Haven addresses the high potential risk of falls in this population through a focus on

assessment, staff training, and development of protocols, physical plant design, furniture, fixtures and safety devices.

5. Need to assist patients with Activities of Daily Living

Geriatric psychiatric patients in nursing homes routinely require assistance with three or more limitations in activities of

daily living), including assistance with ambulation, toileting, bathing, or feeding. When compared to the non-institutionalized elderly, over 90 percent of who have no

limitations, geriatric patients require a staff who can provide psychiatric care as well as nurses and certified nursing assistants who are experienced in providing assistance in basic

skills, which more commonly are requirements for nursing home or medical/surgical patients.

There Is An Insufficient Number of Dedicated Geriatric Psychiatric Beds in the Service Area

Haven states there are an insufficient number of dedicated geriatric

psychiatric beds in the service area. In order to meet the needs of the elderly mental health patients, the applicant believes providers need the following: a dedicated geriatric psychiatric facility or unit to provide

separation of elderly patients from other adults and furnishings, equipment, and policies to prevent falls and minimize harm from unavoidable falls, programs tailored to meet the needs of the psychiatric

needs of the elderly and also specially trained staff. Per the applicant, three providers within the district have a dedicated geriatric psychiatric

unit or program – Florida Hospital/Zephyrhills, Morton Plant Hospital and Windmoor Healthcare of Clearwater


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Below is a chart of the applicant’s description of District 5 adult psychiatric service providers and related data.

District 5 Adult Psychiatric Service Providers

District

Country

Distance

from Haven (Miles)

2009

Utilization Beds

2009 Utilization

Patient Days

2009 Utilization

Occupancy Rate

Dedicated Geriatric

Psych Unit or Program

Community

Hospital

Pasco

27

46

14,605

89.0%

No

Florida Hospital Zephyrhills

Pasco

53*

15

3,344

68.6%

Yes

Morton Plant Hospital

Pinellas

3

54

13,078

71.0%

Yes

St. Anthony’s

Hospital

Pinellas

17

50

14,848

84.1%

No

Sun Coast Hospital**

Pinellas

--

18

5,822

90.5%

No

Windmoor Healthcare of Clearwater

Pinellas

8

78

19,655

73.6%

Yes

Source: CON application #10103, Table 2, page #18. *Per MapQuest (at http://www.mapquest.com/), this distance is 58.4 driving miles, the distance between the applicant’s proposed site and Florida Hospital-Zephyrhills. **Largo Medical Center-Indian Rocks.

The reviewer confirms the applicant’s Table 2 reported 2009 District 5 adult inpatient psychiatric providers, county of operation, bed count,

patient days and occupancy rates. However, as stated previously, District 5 has additional licensed and CON approved but not yet licensed adult inpatient psychiatric beds that came on-line in 2010 (see Section

E.1.a. above). The applicant does not provide more detail on its finding that there are three facilities with “dedicated geriatric psychiatric units or

programs”. Two of these (Morton Plant and Windmoor) are located approximately three and eight miles from Haven’s proposed location.

Focus on Serving the Geriatric Psychiatric Population

The applicant states that its parent, Haven Behavioral Healthcare, Inc., is an experienced provider of dedicated geriatric psychiatric services. Haven has operated dedicated geriatric psychiatric facilities in Phoenix

(Arizona) and Denver (Colorado) with a majority of its patients being between 70-89 years of age. The applicant states that as a geriatric psychiatric provider, Haven understands and employs the resources to

provide psychiatric care that will make a difference in the community. Over 55 percent of Haven’s dedicated geriatric psychiatric patients are

referred from nursing homes and assisted living facilities, 30 percent from patient families and doctors, with approximately 15 percent referred from acute care providers (upon hospital discharge) and other sources,

per the applicant.


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Haven states it has a proven track record of reaching out and working with providers to identify elderly patients who can benefit from geriatric

psychiatric care. Haven’s personnel work closely with area nursing homes and assisted living facilities to assist in identifying residents who

meet admission criteria for inpatient psychiatric care. By specializing in providing only geriatric psychiatric services (which includes re-evaluating and optimizing medication regimens, specialized small-group therapy

sessions, and expertise in placement of elderly patients in the most appropriate site of care) Haven states its personnel are a valuable resource in helping health care providers to meet the needs of geriatric

patients.

Service Area Definition and Demand Projections Haven proposes to serve Pinellas County, with a focus on six zip codes

adjacent to the proposed site. The applicant states that the total service area population is projected to grow slightly by 2,631 total residents over

the next five years, from 912,4724 (actually 921,472) in 2010 to 924,103 in 2015 (by 0.3 percent). The elderly population, according to Haven, is projected to grow at a faster rate from 199,682 in 2010 to 219,964 in

2015, gaining 20,282 persons (increasing by 10.2 percent). Haven states that the elderly percentage of the population in the service area is projected to increase from 21.7 percent in 2010 to “323.8” (actually 23.2

percent)5 in 2015.

4 CON application #10103, page #21 states 2010 service area total population of 912,472 but page #23

states a total service area total population of 921,472. 5 CON application #10103, page #21. However, the applicant’s Table 4 on page #23 indicates an

increase of 23.2 percent by 2015.


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Estimated and Projected Population

District 5 and Service Area District 5

July 1 2010

July 1 2015

Change 2010-2015

Total Population 1,365,722 1,410,972 45,250

Under 65 1,058,453 1,057,081 (1,372)

65 and Over 307,269 353,891 46,622

Percent of Population 65 and Over 22.5% 25.1%

Total Service Area

Total Population 921,472 924,103 2,631

Under 65 721,790 704,139 (17,651)

65 and Over 199,682 219,964 20,282


Pinellas County (Primary Service Area)

Total Population 139,602 140,007 405

Under 65 104,201 101,581 (2,620)

65 and Over 35,401 38,426 3,025


Pinellas County (Secondary Service Area)

Total Population 781,870 784,096 2,226

Under 65 617,589 602,558 (15,031)

65 and Over 164,281 181,538 17,257


Source: CON application #10103, Table 4, page #23. Note: The applicant indicates that the primary service area consists of ZIP Codes 33764, 33670,

33671, 33674, 33576, and 33578. As discussed earlier, these do not appear to be accurate.

The reviewer confirmed the applicant’s July 1, 2010 District 5 population totals as shown. However, for July 1, 2015, with regard to the District 5 population, the applicant understates the under 65 years of age

population and overstates the age 65 and over population by 10,000 residents. The reviewer has previously noted the multiple discrepancies

that exist regarding the applicant’s stated and defined service area(s). Haven states the need for the proposed program is demonstrated by

(1) the underutilization of geriatric psychiatry inpatient care among the elderly population as evidenced through a comparison of existing

utilization in the service area to the expected utilization based on national geriatric inpatient psychiatry admission experience and by (2) the unmet need for increased access to dedicated geriatric psychiatric

care for underserved populations in nursing homes and assisted living facilities. The applicant states that unmet need is evidenced by the low use rate in the service area and the unmet need/access issues associated

with residents in nursing homes and assisted living facilities who need geriatric psychiatric services provided in a programmatic structure and

supportive environment that will meet their specific psychiatric needs. Haven contends this need is not and cannot be readily met in a facility that does not have a separate and distinct geriatric program and

environment. However, the applicant does not address the three geriatric programs it stated are located in its proposed service area.


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Historical versus Expected Geriatric Psychiatric Discharges

2009 Service Area and

Florida Experience and National IPF (Inpatient Facility) Experience 2009

Elderly Population

IPF Use

rate/1,000

Expected

Discharges

Resident

Discharges

Variance

IPF Beds

Needed

Pinellas PSA 34,816 5.33 185 235 50 (3)

Pinellas SSA 160,966 5.33 858 782 (76) 4

Total 195,782 5.33 1,043 1,017 (26) 1

Florida 3,302,610 5.33 17,594 13,603 (3,991) 205 Source: CON application #10103, Table 6, page #25.

The applicant states that the estimated need for one inpatient facility bed

in the service area and 205 inpatient facility beds statewide is conservative, as it:

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

geriatric psychiatry program (65 percent of Medicare inpatient facility

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

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

home and assisted living residents that is not currently being served nationally by geriatric psychiatry programs, and

• does not include the demand generated by seasonal residents.

Haven asserts that the bed need of one represents that the current number of inpatient beds may be reasonable when compared to national experience, although the available beds may not be in a distinct geriatric

unit with specialized geriatric programming.

With a growing elderly population, the applicant states that applying this approach to the 2013 population in the service area (year two of proposed project) will result in a greater unmet need for geriatric

psychiatry beds in both the service area and the state. The applicant estimates an inpatient facility bed need of six by 2013.

Projected Unmet Need for Geriatric Psychiatric Discharges

Using National IPF (Inpatient Facility) Experience

2013 Service Area and State of Florida 2013

Elderly Population

IPF Use rate/1,000

Expected Discharges

2009

Resident Discharges

Variance

2013

IPF Beds Needed

Hernando 37,186 5.33 198 235 (37) (2)

N. Pasco 174,428 5.33 929 782 (147) 8

Total 211,614 5.33 1,127 1,017 (110) 6

Florida 3,658,826 5.33 19,492 13,603 (5,889) 303 Source: CON application #10103, Table 7, page #26.


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The applicant’s table 7 indicates that the service area is Hernando and north Pasco. The applicant’s use of the service area presented in Table 6

(CON application #10103, page 25) and the service area presented in Table 7 (above) continue to add uncertainty as to what is actually the

applicant’s proposed service area. The applicant’s “Summary Unmet Need for Geriatric Inpatient Psychiatric

Beds” (CON application #10103, page 30, Table 11) is presented below.

Source: CON application #10103, page 30.

Haven states that the increased utilization associated with unmet need from nursing homes and ALFs was developed in part based on its

experience in working closely with nursing homes to provide the geriatric psychiatry inpatient needs of their residents. Nursing homes and ALF patients have historically represented 55 percent of Haven’s admissions.

The applicant states implementing a similar program in the service area and working closely with the area nursing homes would result in a

similar distribution of geriatric patients in the proposed facility. Haven states that discharges to nursing homes and ALFs as a result of its entry into the service area are projected to increase by 174 discharges between

2009 and 2013. At 80 percent occupancy, the applicant states that increase would result in a need for 8.9 additional beds associated with

serving the unmet need among nursing home and ALF residents. However, it is unclear how the applicant’s practice of discharging more of its patients than other psychiatric hospitals to nursing homes and ALFs

would result in more admissions to its facility.


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The applicant estimates it will provide 5,505 patient days of care in year one and 11,250 patient days in year two. Haven anticipates 330 total

discharges in year one with an average length of stay to be 15 days, and an average daily census of 15.1 in its proposed 40-bed unit at 37.7

percent occupancy. In year two Haven projects 675 total discharges with an average length of stay 15 days, and an average daily census 30.8 in the 40-bed unit at 77.1 percent occupancy.

In its need summary, the applicant indicates that service area residents would greatly benefit from project approval; however, the applicant does

not document that patients in need of inpatient psychiatric services are not able to access these services. The applicant’s proposed service area

is not clear. Haven does not address the three providers that report to have geriatric programs or units and it is unclear how Haven’s historical discharges to nursing homes and ALFs can be used to show increased

admissions.

The table below shows Calendar Year 2009 Pinellas County psychiatric resident (DRGs 880-887) discharges for patients aged 55 and over and those aged 65 and over. Although the applicant’s service area is not

clear, the reviewer chose Pinellas County based on the proposed facility’s location. The individual facility’s total discharges include all discharges reported by the facility.

Psychiatric Patient Discharges (DRGs 880-887)

Pinellas County Residents Age 55 & Over and Age 65 & Over

CY 2009 Facility & County

Pinellas County

Resident

Discharges

Total Facility

Discharges

Discharges as Percent

of the Facility Total

Age 55 & Over

Age 65 & Over

Age 55 & Over

Age 65 & Over

Community Hospital/Pasco 31 14 15,333 0.20% 0.09%

Largo Medical Center-Indian Rocks/Pinellas 336 165 4,123 8.15% 4.00%

Morton Plant Hospital/Pinellas 589 300 28,178 2.09% 1.06%

St. Anthony’s Hospital/Pinellas 507 219 11,580 4.38% 1.89%

Windmoor Healthcare of Clearwater/Pinellas 391 180 2,545 15.36% 7.07%

Pinellas County Acute Care Hospitals 135 94

Non-District 5 Hospitals/Multiple Counties 68 25

Pinellas County Resident Discharge Total 2057 997 Source: Florida Center for Health Information and Policy Analysis database run date of December 1, 2010 (age 65 or older) and December 10, 2010 (age 55 or older).

As shown above, Windmoor Healthcare of Clearwater and Largo Medical Center Indian Rocks are the facilities most impacted by the project.


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Florida Hospital Zephyrhills, which is located in Pasco County, reported no CY 2009 Pinellas County resident discharges in DRGs 880-887. As

shown above, 1,823 of the 2,057 or 88.62 percent of all Pinellas patients aged 55 and over and 86.65 percent (864/997) of patients aged 65 and

over whom received inpatient psychiatric care received it in Pinellas inpatient psychiatric facilities. These percentages increase to 95.18 percent (aged 55 and over) and 96.08 percent (aged 65 and over) when

acute care facilities are added. Less than four percent (3.3 percent) of Pinellas residents aged 55 and over and 2.5 percent of Pinellas residents aged 65 and over left the district for treatment.

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

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

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

shall provide evidence in their applications that their proposal

is consistent with the needs of the community and other criteria contained in Local Health Council Plans, the district Alcohol, Drug Abuse and Mental Health Plan, and the State

Health Plan.

The applicant discusses mental health issues in the elderly population cited in a report titled “Aging and Mental Health in Florida”.6 Although Florida no longer has a State Health Plan, and

preference criteria for CON review is no longer required of Local Health Council Plans, the appropriate plan for mental health services in Pinellas County is maintained by the Department of

Children and Families. The Department monitors compliance with this plan through an annual survey of facilities in Pinellas County.

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

to ensure access to hospital inpatient general psychiatric

services for Medicaid-eligible and charity care adults, 40 percent of the gross bed need allocated to each district for

hospital inpatient general psychiatric services for adults should be allocated to general hospitals.

District 5 has 278 licensed adult psychiatric beds dispersed among six facilities. Of the six facilities, five are general hospitals and one is freestanding:

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


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District 5 Adult Psychiatric Facilities Facility Type # Adult Beds

Community Hospital General Hospital 46

Florida Hospital Zephyrhills General Hospital 15

Morton Plant Hospital General Hospital 54

St. Anthony’s Hospital General Hospital 50

Largo Medical Center-Indian Rocks General Hospital 35

Windmoor Healthcare of Clearwater Freestanding 78

District 5 Total 278 Source: Florida Hospital Bed Need Projections and Service Utilizations by District, July 2010 Batching Cycle.

With 200 of the 278 beds being located in general hospitals, this represents a 71.94 percent (200/278) allocation to general hospitals. The applicant’s project would change this to 200 of the

318 beds (62.89 percent) being located in general hospitals. There are also 133 CON approved but unlicensed adult inpatient

psychiatric beds in the district as follows:

District 5 CON Approved Currently Unlicensed Beds Facility # Adult Beds

Ten Broeck Tampa, Inc. 35

Morton Plant Hospital Association, Inc. 56

Windmoor Healthcare of Clearwater 42

District 5 Total 133 Source: Florida Hospital Bed Need Projections and Service Utilizations by District, July 2010 Batching Cycle.

Including the applicant’s project in the licensed and approved

count would result in 200 of the 451 total licensed and approved (44.34 percent) being allocated to general hospitals. This criterion

would continue to be met with project approval.

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

Regardless of whether bed need is shown under the need formula, no additional hospital inpatient general psychiatric

beds for adults shall normally be approved in a district unless the average annual occupancy rate of the licensed hospital inpatient general psychiatric beds for adults in the district

equals or exceeds 75 percent for the 12-month period ending six months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

During CY 2009, District 5 had 161 licensed inpatient adult

psychiatric beds and 78.86 percent occupancy, exceeding the 75 percent criterion.


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b. Priority Considerations for hospital inpatient general psychiatric

services (Rule 59C-1.040 (4) (i), Florida Administrative Code) (NOTE: All references to child/adolescent psychiatric services are deleted).

In weighing and balancing statutory and rule review criteria, preference will be given to both competing and non-competing applicants who:

1. Provide Medicaid and charity care days as a percentage of their total patient days equal to or greater than the average

percentage of Medicaid and charity care patient days of total patient days provided by other hospitals in the district, as

determined for the most recent calendar year prior to the year of the application for which are available from the Health Care Board.

The table below shows existing adult psychiatric providers’ amount

of combined CY 2009 Medicaid, Medicaid HMO and charity care.

District 5 Adult Inpatient Psychiatric Facilities

Percentage of Combined Medicaid and Charity Care For FY 2009

Facility

Combined Medicaid/Medicaid HMO

and Charity

Community Hospital 15.0%

Florida Hospital Zephyrhills 15.7%

Morton Plant Hospital 15.6%

St. Anthony’s Hospital 19.5%

Largo Medical Center-Indian Rocks 8.6%

Windmoor Healthcare of Clearwater 2.2% Source: 2009 Agency for Health Care Administration Hospital Financial Data.

The applicant indicates that it will provide 1.5 percent of its total

annual patient days to charity care patients. Haven does not meet this criterion.

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

the extent that these patients can benefit from a hospital-

based organized inpatient treatment program.

Haven states it will serve the most seriously mentally ill geriatric

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

The applicant states that its commitment is evidenced in its admissions criteria, severity of illness criteria, and program limitations (exclusionary criteria).


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3. Propose to serve Medicaid-eligible persons.

Haven states it will provide services to all patients who meet

admission criteria, regardless of ability to pay. However, the applicant does not propose to condition the project to a measurable provision of care to Medicaid patients.

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

Haven states it will provide services to all patients who meet

admission criteria, regardless of ability to pay. However, the applicant does not propose to condition the project to a measurable provision of care to charity care patients.

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

Haven states the 40-bed facility will not be a Baker Act receiving

facility.

c. Minimum Size of Specialty Hospitals (Rule 59C-1.040(3)(e) Florida Administrative Code). A specialty hospital providing hospital inpatient general psychiatric services shall have a minimum total

capacity of 40 beds. The minimum capacity of a specialty hospital providing hospital inpatient general psychiatric services may include beds used for hospital inpatient substance abuse services

regulated under Rule 59C-1.041, Florida Administrative Code. The separately organized units for hospital inpatient general psychiatric

services for adults in specialty hospitals shall have a minimum of 15 beds (Rule 59C-1.040(5), Florida Administrative Code).

Haven proposes a 40-bed adult inpatient psychiatric facility.

d. Access Standard. Hospital inpatient general psychiatric services

should be available within a maximum ground travel time of 45 minutes under average travel conditions for at least 90 percent of

the district's total population (Rule 59C-1.040(6), Florida Administrative Code).

The applicant states that there are inpatient adult psychiatric services within 45 minutes for at least 90 percent of the district’s total

population. The applicant indicates mixed adult psychiatric services are not optimal for elderly patients. However, the applicant states there are three facilities with dedicated geriatric inpatient psychiatric beds in

District 5, two in Pinellas County, Windmoor Healthcare of Clearwater


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(three miles from the applicant’s location) and Morton Plant Hospital (eight miles) and Florida Hospital-Zephyrhills (Pasco County), which the

applicant states is 53 miles from Largo7.

It is noted that the Agency considers adult psychiatric patients to be patients 18 years of age and older. For CON purposes, there is no Agency recognized geriatric designation for adult psychiatric patients.

e. Quality of Care.

1. Compliance with Agency Standards. Hospital inpatient general psychiatric services for adults shall comply with the

Agency standards for program licensure. Applicants who include a statement in their certificate of need application that they will meet applicable Agency licensure standards are

deemed to be in compliance with this provision (Rule 59C-1.040(7)(a), Florida Administrative Code).

Haven states it will meet all of the applicable Agency licensure standards.

2. Continuity. Providers of hospital inpatient general psychiatric

services shall also provide outpatient services, either directly

or through written agreements with community outpatient mental health programs, such as local psychiatrists, local

psychologists, community mental health programs, or other local mental health outpatient programs (Rule 59C-1.040(7)(d), Florida Administrative Code).

Haven states it will work closely with community mental health resources to assure that its patients have access to the full

continuum of mental health services needed to support their requirements. Further, the applicant states it will work closely

with nursing homes and assisted living facilities to identify residents who meet admission criteria for inpatient geriatric psychiatric or another site of care. The applicant will not directly

provide outpatient services but indicates it will refer the patient to the appropriate treatment venue.

7 Per MapQuest (at http://www.mapquest.com/), this distance is 58.4 driving miles, the distance between the applicant’s proposed site and Florida Hospital-Zephyrhills.


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3. Screening Program. All facilities providing hospital inpatient general psychiatric services shall have a screening program to

assess the most appropriate treatment for the patient. Patients with a dual diagnosis of a psychiatric disorder shall be

evaluated to determine the types of treatment needed, the appropriate treatment setting, and, if necessary, the appropriate sequence of treatment for the psychiatric and

substance abuse disorders (Rule 59C-1.040(7)(e), Florida Administrative Code).

Haven states it will make sure all referrals undergo a detailed screening prior to admission. Initial screening is the process of

determining the treatment needs of a patient and coordinating a referral within Haven Behavioral or alternate provider. An inquiry call form is completed on every call. The applicant states that

persons who are not appropriate for admission at Haven will be referred to the appropriate level of care. Callers who present with

an emergency situation will be advised to call 911. Haven states that emergency assessments will be available 24 hours a day, seven days a week.

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

Code). An applicant for hospital inpatient general psychiatric

services shall provide a detailed program description in its certificate of need application including:

1. Age groups to be served.

Haven states it will offer geriatric psychiatric programs designed to meet the psychiatric needs of the elderly and will admit patients 55 years of age and older.

It is noted that the Agency considers adult psychiatric patients to

be patients 18 years of age and older. For CON purposes, there is no Agency recognized geriatric designation for adult psychiatric patients.


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2. Specialty programs to be provided (e.g. programs for eating disorders, stress management programs).

Haven states it will offer geriatric psychiatric services designed to meet the psychiatric needs of the elderly experiencing behavioral

health disorders by providing inpatient behavioral evaluation, treatment, and stabilization. Haven states its philosophy is one of working together with family, physicians, long-term care providers,

and other agencies involved in health care to meet the needs of the elderly.

3. Proposed staffing, including the qualifications of the clinical

director and a description of staffing appropriate for any specialty program.

Position

FTE Year One Ending March 2013

FTE Year Two Ending March 2014

Administrator 1.00 1.00

Director of Nursing 1.00 1.00

Admissions Director 1.00 1.00

Business Development Assistant 2.00 2.00

Secretary 1.00 1.00

Medical Records Clerk 1.00 1.00

Business Development Director 1.00 1.00

Physicians: Unit/Program Director 1.00 1.00

Physicians: Other* 2.00 2.00

RN’s 11.50 11.50

Nurses Aides** 13.00 0.00

Mental Health Techs 0.00 13.00

Other: Psychologist 1.50 1.50

Social Service Director 1.00 1.00

Activity Director 1.00 1.00

Activities Assistant 2.00 2.00

Other: Social Service Assistant 2.50 2.50

Total*** 43.50 43.50 Source: CON application #10103, Schedule 6. *The Agency notes that in year one, this position is shown as “Other:______” but in year two,

this position is shown as “Other: Psychiatrist”. **There are 13.00 FTEs in year one for nurses aides but 0.00 FTEs in year two and in year two, there are 13.00 FTEs for mental health techs but 0.00 FTEs n year one. *** Schedule 6, nor notes to the schedule, indicates any pharmacist FTEs or that such

services will be by contract. However, CON application #10103, page #50 states, “On-site pharmacy services will be provided by a pharmacist and pharmacy technician in a licensed pharmacy” and the applicant proposes to condition the CON to have an on-site pharmacist.

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

Haven lists the following as conditions that exclude individuals from treatment:

Persons who would not benefit from a program designed for the

geriatric population.


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A patient with a history of violent behavior beyond the

capabilities of the staff and physical environment to contain and safely manage the patient with the current patient population.

Medically unstable and/or requiring acute medical hospital

level of care, for example: uncontrolled insulin-dependent diabetes mellitus, changes in level of consciousness, acute

abdominal pain, severe lacerations or trauma/significant bleeding, patients requiring isolation, non-healing wounds, total

immobility, continuous intravenous fluids, or sudden onset severe psychosis/delusions/delirium (prior to medical clearance).

5. Therapeutic approaches to be used.

Haven states it will utilize a combination of medication, psychotherapy and other geriatric specific treatment interventions.

Treatment plans are individualized based on the comprehensive assessments and the identified needs. Treatment for geriatric psychiatric patients at Haven Behavioral Services includes:

Comprehensive initial and ongoing assessments by the

psychiatrist, medical practitioner and clinical staff at admission and throughout the hospital stay.

Medication prescribed by the psychiatrist or other physician with onsite pharmacy services.

Group therapies, including reminiscence, coping with loss, signs and symptoms of treatment issues, self-esteem, medical

education and compliance, life skills, cognition enhancement, and dexterity and movement activities.

Activities therapy: improve reality testing, maximize

independent performance in self-care skills, experience constructive outlets for hostile, aggressive feelings, tension and

anxiety, develop improved physical fitness, sensory perception, and motor skills coordination, and improved cognitive task

skills.

Individual therapy will be provided by therapy staff and/or

psychiatrist and is individualized for each patient’s needs.

Family therapy will be provided by therapy staff or the

psychiatrist as needed to provide education and support to the family on the aging process and behaviors/symptoms associated with the patient’s diagnosis.

The applicant states it will also provide discharge planning which will be developed in collaboration with the patient, family,

treatment team, referring agency, and agencies/facilities the patient will be referred to upon discharge and referral services.


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6. Expected sources of patient referrals.

Haven states it expects referrals to come from nursing homes,

assisted living facilities, patient families, doctors, acute care facilities, emergency room, long-term acute care hospitals, home health agencies and secured Alzheimer’s facilities.

7. Expected average length of stay for the hospital inpatient

general psychiatric services discharges by age group.

Haven states it expects, based on the historical experience of its

parent company, an average length of stay of 15 days. This exceeds the 8.35 days ALOS for Pinellas patients aged 55 and over in DRGs 880-887 in CY 2009.

8. Projected number of hospital inpatient general psychiatric

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

completion of the proposed project.

The applicant states that as a geriatric psychiatric provider, almost

all patient days are projected to be provided to Medicare and Medicare HMO patients.

Payer Mix for Proposed Service

Payer Year One Year Two

Medicare 73.4% 80.5%

Medicare HMO 9.1% 10.0%

Commercial 5.0% 5.0%

Self-Pay/Charity 12.5% 4.5%

Total 100.0% 100.0% Source: CON application #10103, Table 14, page #52.

The hospital will not be a Baker Act receiving facility. Charity care is stated to be 1.5 percent of the project’s total annual patient days

but is not conditioned. 9. Admission policies of the facility with regard to charity care

patients. Haven states it will provide geriatric services to all patients

regardless of payer source. Haven states its admissions policy for charity care patients requires each patient to complete a financial

assistance application which is designed to collect the income level and related documentation in accordance with applicable state


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law. Persons eligible for Medicaid who receive services not covered by Medicaid are considered to be financially indigent. The

applicant lists the following as factors considered in determining the eligibility for charity care:

Gross income

Family size

Employment status and future earning capacity

Other financial assets and resources

Other financial obligations

Amount and frequency of facility/medical bills

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

Code). Facilities providing licensed hospital inpatient general

psychiatric services shall report to the agency or its designee, within 45 days after the end of each calendar quarter, the number of

hospital inpatient general psychiatric services admissions and patient days by age and primary diagnosis ICD 9 code.

Haven states it will report to the Agency or its designee, within 45 days after the end of each calendar quarter, the number of hospital inpatient

general psychiatric services admissions and patient days by age and primary diagnosis ICD-9 code.

4. Statutory Review Criteria

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

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

In Volume 36, Number 29, dated July 23, 2010 of the Florida Administrative Weekly, a fixed need pool of zero beds was published for

adult inpatient psychiatric beds in District 5 for the January 2016 planning horizon. The applicant is not responding to a fixed need pool but rather on what the applicant considers “not normal” circumstances.

District 5 has 278 licensed adult inpatient psychiatric beds and 133 approved adult inpatient psychiatric beds.

As previously stated, District 5 experienced an occupancy rate of 78.86 percent during the 12-month period ending December 31, 2009.


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Haven states there are three facilities with dedicated geriatric inpatient psychiatric beds in District 5, Windmoor Healthcare of Clearwater and

Morton Plant Hospital (Pinellas County) and Florida Hospital-Zephyrhills (Pasco County), which the applicant states is 53 miles from Largo. Also,

the applicant provides excerpts from its letters of support as evidence of need.

The applicant indicates that service area residents would greatly benefit from project approval; however, the reviewer has noted that there are multiple discrepancies regarding the applicant’s stated and defined

service area.

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

patients 18 years of age and older. For CON purposes, there is no Agency recognized geriatric designation for adult psychiatric patients.

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

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

care? ss. 408.035(1)(c), Florida Statutes. Haven Behavioral Health Services of Florida, LLC is a newly created,

wholly-owned subsidiary of Haven Behavioral Healthcare, Inc., ultimately parented by Haven Behavioral Healthcare Holdings, LLC. This entity does not currently provide services in the State of Florida. Haven states

it has a history of providing quality care to the community members it serves and has received the gold seal of approval from The Joint

Commission in six of its hospitals. The applicant states it has an extensive performance improvement plan that will be implemented. Haven provides its scope of quality and performance improvement

activities for its North Denver facility, and its performance improvement plan in the application’s attachment Q.

Haven provides a brief description of its ability to provide quality care and indicates that it will apply for Joint Commission accreditation within

one year of beginning operations.

c. What resources, including health manpower, management

personnel, and funds for capital and operating expenditures, are available for project accomplishment and operation?

ss. 408.035(1)(d), Florida Statutes.

Haven Behavioral Health Services of Florida, LLC’s audited financial

statements were reviewed to assess the financial position as of the balance sheet date and the financial strength of its operations for the period presented.


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The applicant is a development stage corporation established in 2010 to acquire and operate behavioral health care facilities. According to the

audit, the applicant has $240,000 in total assets and $40,000 in intercompany payables and with no operations.

The applicant provided audited financial statements of its ultimate parent company, Haven Behavioral Healthcare Holdings, LLC, a for-profit

corporation, for the periods ending December 31, 2009 and 2008. These statements were analyzed for the purpose of evaluating the parent’s ability to provide the capital and operational funding necessary to

implement the project. Short-Term Position:

The parent’s current ratio of 2.2 is slightly above average and indicates current assets are over two times current liabilities, a good position. The

working capital (current assets less current liabilities) of $18.4 million is a measure of excess liquidity that could be used to fund capital projects. The ratio of cash flow to current liabilities of 0.4 is below average and a

weak position. Overall, the parent has an adequate short-term position. (See table below).

Long-Term Position: The ratio of long-term debt to net assets of 0.7 percent is above average

and indicates that the parent may have difficulty obtaining future debt financing if necessary. The ratio of cash flow to assets of 3.7 percent is well below average and a weak position. The most recent year had

revenues in excess of expenses of $131,925, which resulted in a 0.1 percent operating margin (roughly break even). Taking into account non-

operating costs of $4,681,071, the parent had a loss before income taxes of $4,549,146. Overall, the parent has a moderately weak long-term position. (See table below).

Capital Requirements:

Schedule 2 indicates total capital projects of $8,579,315, which includes the CON subject to this review and CONs 10102, 10094, and 10095. In addition to capital costs, the applicant is projecting a year one operating

loss for each of the above listed CONs (see table below) which it will have to fund until profitability can be achieved. CON Number

Project Costs

Year One Operating Loss

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

10102 $2,204,540 $ 831,025

10094 $1,913,485 $ 609,566

10095 $1,881,983 $ 924,318

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


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

the project will be provided by the parent. In support of the related company financing, the applicant provided a letter from the parent

expressing it will provide the applicant financing from available cash on hand and from an alternate source in the form of a $25,000,000 line of credit from Regions Bank. The parent’s 2009, audited financial

statements indicate $18.4 million in working capital and 6.3 million in cash flows from operations. In addition, the applicant included a copy of a letter from Regions Bank dated October 12, 2010, indicating a

revolving line of credit of $25,000,000 available. The line of credit is also referenced in the parent’s audit.

Staffing: Position

FTEs Year One Ending March 2013

FTEs Year Two Ending March 2014

Administrator 1.00 1.00

Director of Nursing 1.00 1.00

Admissions Director 1.00 1.00

Business Development Assistant 2.00 2.00

Secretary 1.00 1.00

Medical Records Clerk 1.00 1.00

Business Development Director 1.00 1.00

Physicians: Unit/Program Director 1.00 1.00

Physicians: Other* 2.00 2.00

RN’s 11.50 11.50

Nurses Aides** 13.00 0.00

Mental Health Techs 0.00 13.00

Other: Psychologist 1.50 1.50

Social Service Director 1.00 1.00

Activity Director 1.00 1.00

Activities Assistant 2.00 2.00

Other: Social Service Assistant 2.50 2.50

Total*** 43.50 43.50 Source: CON application #10103, Schedule 6. *The Agency notes that in year one, this position is shown as “Other:______” but in year two, this position is shown as “Other: Psychiatrist”.

**There are 13.00 FTEs in year one for nurses aides but 0.00 FTEs in year two and in year two, there are 13.00 FTEs for mental health techs but 0.00 FTEs in year one. ***Schedule 6, nor notes to the schedule, indicates any pharmacist FTEs or that such services will be by contract. However, CON application #10103, page #50 states , “On-site pharmacy services will be

provided by a pharmacist and pharmacy technician in a licensed pharmacy” and the applicant proposes to condition the CON to have an on-site pharmacist.

Conclusion:

Funding for this project and the entire capital budget should be available as needed. While the architectural review indicates that the project

costs are likely to increase significantly if additional work is needed for the project to meet architectural and mandated code requirements, based on the applicant’s available funding sources, this possible higher

cost does not change the Agency’s conclusion about the applicant’s ability to fund the project and the entire capital budget.


34

Haven Behavioral Services of Florida, LLC – CON Application #10103

Parent Parent

12/31/09 12/31/08

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

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

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

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

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

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

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

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

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

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

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

FINANCIAL RATIOS

12/31/09 12/31/08

Current Ratio (CA/CL) 2.2 1.6

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

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

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

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

Operating Margin (ER/TR) 0.1% 2.2%

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

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

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

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

A comparison of the applicant’s estimates to the control group values provides for an objective evaluation of financial feasibility, (the likelihood that the services can be provided under the parameters and conditions

contained in Schedules 7 and 8), and efficiency, (the degree of economies achievable through the skill and management of the applicant). In general, projections that approximate the median are the most desirable,

and balance the opposing forces of feasibility and efficiency. In other words, as estimates approach the highest in the group, it is more likely

that the project is feasible, because fewer economies must be realized to achieve the desired outcome.

Conversely, as estimates approach the lowest in the group, it is less likely that the project is feasible, because a much higher level of

economies must be realized to achieve the desired outcome. These relationships hold true for a constant intensity of service through the relevant range of outcomes. As these relationships go beyond the

relevant range of outcomes, revenues and expenses may, either, go beyond what the market will tolerate, or may decrease to levels where activities are no longer sustainable.


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The applicant will be compared to hospitals in the Short-Term

Psychiatric Hospital Group (Group 15). A case mix of 0.8439 was calculated for the psychiatric discharges (non-surgical MDC 19, age 55

and over) in Pinellas County for 2009. On page 21 of the application, the applicant indicated that the primary service area would be in zip codes 33564, 33570, 33571, 33574, 33576, and 33578. This appears to be an

error as these zip codes are in Hillsborough and Pasco Counties rather than Pinellas. Therefore, these zip codes were not included in our calculation of case mix. Per diem rates are projected to increase by an

average of 2.7 percent per year. Inflation adjustments were based on the new CMS Market Basket, 2nd Quarter, 2010.

Gross revenues, net revenues, and costs were obtained from Schedules 7 and 8 in the financial portion of the application and compared to the

control group as a calculated amount per adjusted patient day.

Projected net revenue per adjusted patient day (NRAPD) of $650 in year one and $724 in year two is between the control group median and highest values of $631 and $763 in year one and $649 and $785 in year

two. With net revenues falling between the median and highest level, the facility is expected to consume health care resources in proportion to the services provided. (See table below).

Anticipated costs per adjusted patient day (CAPD) of $860 in year one

and $651 in year two is between the control group median and highest values of $707 and $1,257 in year one and between the lowest and median values of $532 and $728 in year two. With projected cost

between the median and highest value in the control group in year one, and between the low and median values in year two, costs appear reasonable. (See table below). The applicant is projecting a decrease in

CAPD between year one and year two from $860 to $651, or 24.3 percent. It should be noted that this application is for a new facility.

The first year of operation has a below average occupancy rate. The low occupancy rate decreases economies of scale and as the occupancy rate increases, CAPD would be expected to decrease.

The year two projected operating income for the project of $820,052

computes to an operating margin per adjusted patient day of $73, or 10.1 percent, which is between the control group median and highest values of negative $33 and $87.

Conclusion: This project appears to be financially feasible.


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Haven Behavioral Services of Florida, LLC

CON Application #10103 Dec-13 YEAR 2 VALUES ADJUSTED

2009 DATA Peer Group 15 YEAR 2 ACTIVITY FOR INFLATION

ACTIVITY PER DAY Highest Median Lowest

ROUTINE SERVICES 8,147,250 724 1,824 1,317 619

INPATIENT AMBULATORY 0 0 0 0 0

INPATIENT SURGERY 0 0 0 0 0

INPATIENT ANCILLARY SERVICES (P) 378,675 34 249 0 0

OUTPATIENT SERVICES (Q) 0 0 299 18 0

TOTAL PATIENT SERVICES REV. (R) 8,525,925 758 1,884 1,453 981

OTHER OPERATING REVENUE 0 0 72 1 0

TOTAL REVENUE 8,525,925 758 1,887 1,454 988

DEDUCTIONS FROM REVENUE 383,667 34 0 0 0

NET REVENUES 8,142,258 724 785 649 486

EXPENSES

ROUTINE 3,382,642 301 707 272 127

ANCILLARY 679,206 60 209 28 0

AMBULATORY 0 0 0 0 0

TOTAL PATIENT CARE COST 4,061,848 361 0 0 0

ADMIN. AND OVERHEAD 1,998,986 178 0 0 0

PROPERTY 1,025,839 91 0 0 0

TOTAL OVERHEAD EXPENSE (V) 3,024,825 269 963 409 190

OTHER OPERATING EXPENSE 235,533 21 0 0 0

TOTAL EXPENSES 7,322,206 651 1,293 728 532

OPERATING INCOME 820,052 73 87 -33 -562

10.1%

PATIENT DAYS 11,250

ADJUSTED PATIENT DAYS 11,250

TOTAL BED DAYS AVAILABLE 14,600 VALUES NOT ADJUSTED

ADJ. FACTOR 1.0000 FOR INFLATION

TOTAL NUMBER OF BEDS 40 Highest Median Lowest

PERCENT OCCUPANCY 77.05% 94.7% 66.3% 18.8%

PAYER TYPE PATIENT DAYS % TOTAL

SELF PAY 506 4.5%

MEDICAID (BA) 0 0.0% 0.0% 0.0% 0.0%

MEDICAID HMO 0 0.0%

MEDICARE (AW) 9,056 80.5% 95.6% 49.0% 15.8%

MEDICARE HMO 1,125 10.0%

INSURANCE 563 5.0%

HMO/PPO (BF) 0 0.0% 71.5% 35.4% 2.4%

OTHER 0 0.0%

TOTAL 11,250 100%


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

The applicant is applying to establish a new 40-bed inpatient adult

psychiatric hospital in District 5 dedicated to geriatric psychiatric patients. According to the applicant, the currently dedicated geriatric inpatient psychiatric beds in District 5 are two Pinellas County providers,

Windmoor Healthcare of Clearwater, and Morton Plant Hospital and Florida Hospital Zephyrhills in Pasco County, which is 53 miles from Largo. Therefore, this project would introduce a new geriatric psychiatric

provider to the area.

General economic theory indicates that competition ultimately leads to lower costs and better quality. However; in the health care industry there are several significant barriers to competition:

Price-Based Competition is Limited - Medicare accounts for almost 50

percent of short-term psychiatric hospital charges in Florida, while HMO/PPOs account for approximately 34 percent of charges. While HMO/PPOs negotiate prices, fixed price government payers like Medicare

and Medicaid do not. Therefore price-based competition is limited to non-government fixed price payers. Price-based competition is further restricted as Medicare reimbursement in many cases is seen as the

starting point for price negotiation among non-government payers. In this case, the applicant projects 76.8 percent of its projected patient days

will come from Medicare and 4.5 percent from Medicare HMO. The User and Purchaser of Healthcare are Often Different – Roughly 84

percent of short-term psychiatric hospital charges in Florida are from Medicare, Medicaid, and HMO/PPOs. The individuals covered by these

payers pay little to none of the costs for the services received. Since the user is not paying the full cost directly for service, there is no incentive to shop around for the best deal. In addition, users are restricted only to

the choices included in the insurance plan. This further makes price based competition irrelevant.

Information Gap for Consumers – Price is not the only way to compete for patients, quality of care is another area in which hospitals can compete.

However, there is a lack of information for consumers and a lack of consensus when it comes to quality measures. In recent years there have been new tools made available to consumers to close this gap.

However, transparency alone will not be sufficient to shrink the information gap. The consumer information must be presented in a manner that the consumer can easily interpret and understand. The

beneficial effects of economic competition are the result of informed choices by consumers.


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In addition to the above barriers to competition, a study presented in The Dartmouth Atlas of Health Care 2008 suggests that the primary cost

driver in Medicare payments is availability of medical resources. The study found that excess supply of medical resources (beds, doctors,

equipment, specialist, etc.) was highly correlated with higher cost per patient. Despite the higher costs, the study also found slightly lower quality outcomes. This is contrary to the economic theory of supply and

demand in which excess supply leads to lower price in a competitive market. The study illustrates the weakness in the link between supply and demand and suggests that more choices lead to higher utilization in

the health care industry as consumers explore all alternatives without regard to the overall cost per treatment or the quality of outcomes.

Conclusion: Although a new provider for geriatric psychiatric care would be added to

District 5, due to the health care industry’s existing barriers in consumer based competition, this project will not likely have a material impact to

foster the type competition generally expected to promote quality and cost-effectiveness.

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

they comply with statutory and rule requirements? ss. 408.035(1)(h), Florida Statutes; Ch. 59A-3, Florida Administrative Code.

Haven Behavioral Health Services of Florida, LLC (CON #10103): The new hospital would be located on the third and fourth floor of a building

described as “a former Diagnostic Center in Largo”. Neither the narrative nor the plans indicate the construction type of the project. The building

will likely require extensive renovations to comply with the requirements of a new I-2/health care occupancy. Also, there is no indication that the building will be owned by the applicant or another licensed healthcare

provider and the applicant states the site will be leased. This condition is not permitted under current state regulations.

The plans and narrative indicate that patients will be located on the fourth floor of the building and administrative areas will be located in

small portion of the third floor below the patient area. The use and layout of the remainder of the third floor is not addressed by this submission. The Life Safety Code (National Fire Protection Association

101) requires that all floors located directly below a healthcare occupancy be sub-divided into smoke compartments. This could present

a problem if the occupant of the second floor is not a health care occupancy or did not grant access of the floor for the life safety use of the hospital.


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The psychiatric nursing unit would consist of 20 semi-private patient rooms. All patient rooms would have a toilet/shower room that could be

accessed without going into the corridor. Some of the semi-private patient rooms appear to be too small to comply with current code

requirements. The narrative indicates that two patient toilet rooms will be handicap accessible to meet 10 percent accessibility requirements of the Florida Building Code (FBC).

The new hospital does not appear to provide a nourishment station in the psychiatric unit as required by code. A small kitchenette is provided

on the third floor in the administrative area, but this does not satisfy the nourishment requirement for the psychiatric unit on the floor above.

There is no dietary department shown on the plans, so it is assumed that meals will be prepared off site and delivered to the facility by a food service vendor. Provision must be made to protect food being delivered

from the weather.

Other functional spaces for a psychiatric hospital have been provided and are adequately sized. Some modifications may be necessary to provide the direct nurse supervision required of the two seclusion rooms.

A patient dining area is not indicated on the plans, but there is adequate space in the social space to accommodate this function.

There is no mention of the disaster preparedness requirement of the Florida Building Code. All exterior openings will be required to be

protected from debris impact in accordance with FBC 419.4.2.5. The project summary on the plan indicates that the project will comply

with current codes. Some additional architectural, mechanical and electrical physical plant standards such as the nurse call, generator requirements, and door hardware will need to be addressed as more

detailed construction documents are produced, but the physical constraints of the spaces should accommodate these requirements.

The estimated construction costs for the project appears to be based on an incomplete understanding of the scope of work. Costs are likely to

increase significantly if additional work is needed to bring the construction type of the building up to current requirements for an

I-2/health care occupancy. Additionally, cost may increase if all of the existing building’s exterior units are not designed to resist the impact of storm debris as required by the Florida Building Code.

Ownership of the portion of the building not occupied by the proposed new hospital is a concern. It may be necessary for the applicant or

another licensed hospital to purchase the entire building. Additionally, careful examination of the existing building is needed to determine the


40

extent of work (if any) that will be required to comply with the construction type requirements of the Florida Building Code and Life

Safety Code for a four-story hospital.

The architectural review of the application shall not be construed as an in-depth effort to determine complete compliance with all applicable codes and standards. The final responsibility for facility compliance

ultimately rests with the owner.

g. Does the applicant have a history of providing health services to

Medicaid patients and the medically indigent? Does the applicant propose to provide health services to Medicaid patients and the

medically indigent? ss. 408.035(1)(i), Florida Statutes.

The applicant is not an existing health service provider in Florida.

However, the applicant states that Haven Behavioral Services, Inc. has a history of providing service to all patients regardless of payer class or

ability to pay. The applicant projects that charity care patient days will represent 1.5 percent of total patient days. Schedule 7B and notes to the schedule show that the applicant will be providing 12.5 percent of year

one’s and 4.5 percent of year two’s patient days to self-pay/charity/other unreimbursed patients.

The applicant does not propose to condition project approval to the provision of care to Medicaid/Medicaid HMO or charity care patients.

F. SUMMARY

Haven Behavioral Health Services of Florida, LLC (CON #10103) proposes to establish a 40-bed adult inpatient psychiatric hospital on leased property at 1551 West Bay Drive, in the City of Largo, Pinellas

County, Florida. The applicant proposes four conditions to project approval (see Item C -

Project Summary, pages 6-7).

Total project cost is $2,579,307. The project involves 20,380 GSF of renovation and total construction cost of $1,365,253.


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Need

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

Administrative Weekly, a fixed need pool of zero was published for adult inpatient psychiatric beds in District 5 for the January 2016 planning horizon. District 5 has 278 licensed and 133 approved adult inpatient

psychiatric beds. During CY 2009, District 5 had 261 licensed beds and 78.86 percent occupancy. The applicant is applying outside the fixed

need pool. Haven states the need for geriatric psychiatric services is not being met

by existing providers in District 5. Haven’s proposed service area is not clear. The multiple service area configurations introduced by the applicant make it impossible to determine a single service area that can

be uniformly applied throughout the applicant’s need justification.

The applicant states the following “not normal” circumstances support need for the project:

District 5 and service area elderly receive disproportionately less inpatient psychiatric care than other adults and that statewide rate,

mental health conditions in older adults are not being addressed,

service area nursing home residents have unaddressed behavioral

health disorders,

dedicated geriatric psychiatric beds in the service area are

insufficient, and

the applicant has a focus on serving the geriatric psychiatric

population.

Per the applicant, three providers within the district have a dedicated geriatric psychiatric unit or program – Florida Hospital/Zephyrhills,

Morton Plant Hospital and Windmoor Healthcare of Clearwater. However, Haven does not address their occupancy or programs they provide. The applicant estimates it will provide 5,505 patient days of care in year one

and 11,250 patient days in year two. Haven anticipates an ALOS of 15 days during years one and two.

Pinellas County residents age 55 years and over who received inpatient psychiatric care during CY 2009, had an ALOS of 8.35 days. The

applicant’s projected ALOS would exceed the national average of 12.4 days for patients in freestanding facilities by 2.6 days.

Haven’s projected bed need is stated to be based on national use rates applied to the service area and its historical discharge of a larger

percentage of its patients to nursing homes and ALFs than existing service area providers. The use of a national use rate applied to the service area does not demonstrate that existing providers are not meeting


42

the need. Haven does not document that patients in need of adult inpatient psychiatric services are not able to access these services. It is

unclear how the applicant’s historical discharge pattern could be used to project more admissions.

Haven does not propose to be a Baker Act receiving facility.

For CON purposes, adult inpatient psychiatric services are evaluated for patients age 18 and over; however, the applicant plans to serve patients aged 55 and over. The applicant states that persons who are not

appropriate for admission at Haven will be referred to the appropriate level of care. Callers who present with an emergency situation will be

advised to call 911.

Quality of Care

The applicant is a newly created entity, with no history of providing care

in the State of Florida. Haven states it has a history of providing quality care and has received the gold seal of approval from The Joint Commission in six of its hospitals. The applicant provides a performance

improvement plan that will be implemented, quality and performance improvement activities, and a performance improvement plan.

Cost/Financial Analysis

Funding for this project and the entire capital budget should be available as needed. While the architectural review indicates that the project costs are likely to increase significantly if additional work is needed for the

project to meet architectural and mandated code requirements, based on the applicant’s available funding sources, this possible higher cost does not change the Agency’s conclusion about the applicant’s ability to fund

the project and the entire capital budget.

Assuming the applicant will be able to meet the assumptions for patient days and payer mix, the project appears to be financially feasible.

Medicaid/Indigent Care

The applicant states that charity care patient days will represent 1.5 percent of total patient days.

Schedule 7 indicates that 12.5 percent of year one and 4.5 percent of year two patient days will be provided to charity care and self-pay patients.

The applicant does not propose Medicaid or charity care conditions.


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Architectural Analysis

The applicant proposes to establish a 40-bed adult (geriatric) inpatient psychiatric hospital located on the third and fourth floor of a building

described as a former diagnostic center in the City of Largo (Pinellas County), Florida. Haven states that it will lease the building; however, this is not permitted under current state regulations. Ownership of the

portion of the building not occupied by the proposed new hospital is a concern. It may be necessary for the applicant or another licensed hospital to purchase the entire building.

Neither the narrative nor the plans indicate the construction type of the

project, nor do they indicate that all floors located directly below health care occupancy floors will be sub-divided into smoke compartments, as required by The Life Safety Code (National Fire Protection Association

101). Further, there is no mention of the disaster preparedness requirement of the Florida Building Code (FBC) and specifically FBC

419.4.2.5. The estimated construction costs for the project appears to be based on

an incomplete understanding of the scope of work. Costs are likely to increase significantly if additional work is needed for the project to meet architectural and mandated code requirements.

G. RECOMMENDATION

Deny CON #10103


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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 report - agency for health care administration

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