STATE AGENCY ACTION REPORTahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10085.pdf · and/or the possible creation of an inpatient unit. These include Michael Bokor, CEO of Southern

STATE AGENCY ACTION REPORT

ON APPLICATION FOR CERTIFICATE OF NEED

A. PROJECT IDENTIFICATION

1. Applicant/CON Action Number

Compassionate Care Hospice of Florida, Inc./CON #10083

200 Lanidex Plaza, Suite 2101

Parsippany, New Jersey 07054

Authorized Representative: Ms. Judith Grey

(973) 402-4712

Douglas Gardens of Broward, Inc./CON #10084

5200 N.E. 2nd Avenue

Miami, Florida 33137

Authorized Representative: Mr. Jeffrey P. Freimark

(305) 762-1392

Hospice of Palm Beach County, Inc./CON #10085

5300 East Avenue

West Palm Beach, Florida 33407-2387

Authorized Representative: Mr. David Fielding

(561) 848-5200

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida/CON #10086

717 North Harwood, Suite 1500

Dallas, Texas 75201

Authorized Representative: Mr. Jason S. Howard

(214) 922-9711

2. Service Area/Subdistrict

District 10, Hospice Service Area 10, Broward County

CON Action Numbers: 10083, 10084, 10085 and 10086

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B. PUBLIC HEARING

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

establish a hospice program in Hospice Service Area 10. However, letters

of support were submitted, as discussed below.

Compassionate Care Hospice of Florida, Inc. (CON #10083) has 37

letters of support for its project, 33 are from Hospice Service Area (HSA)

10. These include representatives of three hospitals, 10 physicians, six

skilled nursing facilities, six assisted living facilities, a city official, four

care management and home care service providers, Nova Southeastern

University, and three members of the religious community. Rabbis

Tennenhaus, Mann and Davis indicate that “none of the established

hospices provide a program designed to address Jewish tradition with

respect to end of life issues”. Four of the applicant‟s letters of support

are from out of state providers. These include two hospital executives (of

Delaware and New Jersey hospitals), a physician from New Jersey, and a

social worker from New Jersey.

Plantation General Hospital CEO, Barbara J. Simmons, R.N. and Kindred

Hospitals South Florida Executive Director, Theodore L. Welding

(representing Kindred Hospital Fort Lauderdale and Kindred Hospital

Hollywood) indicate that they are willing to enter into agreements with

Compassionate Care to provide inpatient hospice care and specific to

Kindred, provide Compassionate Care as an option in the discharge

planning process. Three Broward County nursing home executives

indicate their willingness to enter into agreements for inpatient services

and/or the possible creation of an inpatient unit. These include Michael

Bokor, CEO of Southern SNF Management on behalf of the Palms

Rehabilitation and Nursing Center (a 120-bed community nursing home),

John T. Miller Executive Director of The Forum at Deer Creek, a

continuing care retirement community with 60 community nursing home

beds and Melinda Skirvin, the administrator of Park Summit, a

continuing care rental retirement community with 35 community

nursing home beds.

Associate Dean of Nursing, Diane Whitehead, EdD RN states that in

addition to enhancing patient choice, Compassionate Care can assist

Nova Southeastern in its mission of preparing culturally sensitive and

competent nursing leaders who have knowledge and skills that are


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relevant, futuristic, and responsive to rapidly changing health care

trends and environments. Compassionate Care proposes to condition

approval to partner with Nova Southeastern University‟s College of Allied

Health and Nursing to provide a clinical rotation site to students seeking

a nursing degree.

City of Hallandale Beach Commissioner, Keith S. London states he is

impressed with the information he received about Compassionate Care

and area residents would be particularly interested in Compassionate

Care‟s “specialized programs for Jewish hospice patients, as well as their

specialized Spanish language staff and materials to outreach to Hispanic

residents in the area”. He emphasizes the need for a hospice in the

community that has experience in working with diverse communities.

Many letters of support emphasize that Compassionate Care is an

experienced provider committed to providing continuous care (at home or

wherever the patient lives) that is beneficial for terminally ill patients and

their families.

Douglas Gardens of Broward County, Inc. (CON #10084) includes 41

letters of support with its application. Five are from Service Area 10.

These include Broward County Human Services Department, Elderly and

Veterans Services Division Director, Stephen Ferrante, MSW; Diana Food

Group President, Rick Wodnicki, Easter Seals South Florida, Inc. Senior

Director, Angela Aracena, Aging & Disability Resource Center of Broward

County Executive Director, Edith Lederberg, and Pompano Rehabilitation

and Nursing Center, Jeff Nusbaum, NHA. The remaining 36 letters are

from hospitals, physicians, assisted living facilities, skilled nursing

facilities and heath care management companies in Miami Lakes,

Florida, Wisconsin, Pennsylvania, Illinois, California, Michigan, and

Maryland. With the exception of the two letters from medical staffing

companies in Miami Lakes, Florida who wrote in support of Douglas

Gardens Hospice, Inc., the non-service area letters are in support of

Seasons Hospice and Palliative Care. These letters reference Seasons‟

ability to significantly increase access for patients in need of hospice and

palliative care and to provide a highly improved continuum of care for the

patients and the community. These letters also favorably discuss

Seasons‟ open access policy that places emphasis on no patient being

rejected simply because they choose to continue some element of life-

sustaining therapy.


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State Representative Joseph Gibbons, District 105 states that the

applicant‟s personalized approach to helping patients and families‟ going

through such a difficult time is truly inspiring and commendable. He

goes on to state the care is immaculate and their services are to be

applauded.

Jeff Nusbaum, NHA, Pompano Rehabilitation and Nursing Center

(a 127-bed community nursing home) states he would be willing to

contract with Douglas Gardens Hospice/Seasons “for general inpatient

levels of care”. Mr. Nusbaum also compliments Douglas

Gardens/Seasons‟ on their dedication to meeting the needs of the

patients and families.

Hospice of Palm Beach County, Inc. (CON #10085) includes 81 letters

of support with its application. Forty-four of these letters are from

HSA 10 hospitals, skilled nursing facilities, assisted living facilities,

physicians, government officials, local residents, institutions of higher

education, minority groups, and members of the religious community.

Of those 44 letters, eight are from HSA 10 skilled nursing facilities and

one is from a hospital expressing willingness to enter into contracts for

inpatient services: Northwest Medical Center CEO, Dianne Goldenberg,

Life Care Center at Inverrary Executive Director, Pamela Allison, West

Broward Care Center Administrator, Zev Shemesh, SeaView Nursing &

Rehabilitation Center Administrator, John Glass, Broward Nursing &

Rehabilitation Center Administrator, John Hymans, The Health Center of

Coconut Creek Administrator, Shawn Corley, Harbor Beach Nursing &

Rehabilitation Center Administrator, Marie Simeus, Hillcrest Nursing &

Rehabilitation Center Administrator, Armando Fernandez, and Fort

Lauderdale Health & Rehabilitation Center President and CEO,

Ken C. Angel.

State Representative Hazelle P. Rogers, District 94, Democratic Deputy

Whip states that quality of care during the final days is very important

and dear to any family member dealing with the pending loss of a loved

one. Representative Rogers states that it is “wonderful to hear that our

community may have a chance to get more access to Hospice of Palm

Beach County in the near future” and her appreciation of “those

providers who go out of their way to market this service in the under

serviced community that I represent”.


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Howard Berger, City of Lauderhill Commissioner states that the

applicant is well-known for its ability to establish access to hospice

services and its philosophy of open access to care, commitment to

serving indigent and underserved populations and extraordinary service.

Commissioner Berger asserts that a hospice of this caliber will enhance

health care services throughout the community.

Josie Bacallao, President/CEO of Hispanic Unity of Florida, states that

her agency is the largest non-profit agency in Broward County dedicated

to the immigrant population and provides 26 programs in three

languages to Broward County‟s diverse community. Ms. Bacallao

indicates that during 2009, Hispanic Unity served 25,000 clients, from

infants to seniors. She indicates that the applicant has a strong track

record of providing care to the indigent, and of meaningful outreach to

underserved populations such as immigrants and Hispanics. She states

that Hospice of Palm Beach County has several Hispanics and Spanish

speaking individuals on its executive leadership team, which supports

their core value of being truly committed to care for all people. Ms.

Bacallao concludes that with the growth in Broward‟s Spanish speaking

senior population, her organization would welcome the services of the

applicant in Broward County.

Anthony J. Silvagni, D.O., Dean of Nova Southeastern University‟s

School of Osteopathic Medicine in Fort Lauderdale indicates that Nova

Southeastern and Hospice of Palm Beach County (HPBC) have an

outstanding educational relationship and that 2nd, 3rd, and 4th year

medical students travel 120 miles round trip to participate in the

excellent teaching program at HPBC. They also have partnered with

HPBC to create a Hospice and Palliative Medicine Fellowship program

and anticipate full accreditation of this fellowship in July 2010. Dr.

Silvagni indicates that the university and the community would benefit

from HPBC providing care in Broward County.

The remaining 37 letters of support are from health care management

companies, hospitals, physicians, residents, continuing care retirement

communities, skilled nursing facilities and assisted living facilities

located outside of HSA 10, Broward County. Many of these are from HSA

9C where the applicant currently has a hospice program. These letters

discuss Hospice of Palm Beach County‟s philosophy of open access to

care and its commitment to serving the indigent and underserved

populations. Some note their previous experiences with the applicant as

both rewarding and impressive, stating Hospice of Palm Beach County is

uniquely qualified to provide improved palliative care.


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Odyssey HealthCare of Collier County, Inc. (CON #10086) submitted

53 letters of support with its application. These letters are from

hospitals, a United States congressional representative, Florida

legislators, city officials, Jewish community organizations, physicians,

health care providers, and local residents. Thirty-five of these are from

HSA 10. Six are from representatives of five hospitals that state a

willingness to contract for general inpatient services for hospice care:

Westside Regional Medical Center CEO, Mary Lynn Swartz, Plantation

General Hospital CEO, Barbara J. Simmons R.N., Kindred Hospital

South Florida-Fort Lauderdale Administrator, Jason Zachariah, Kindred

Hospital South-Florida Hollywood Administrator, Chris Clements,

Kindred Hospitals South Florida Executive Director, Theodore Welding,

GEO Care, Inc. South Florida State Hospital, Hospital Administrator

Diane Funston MS, RN, FACHE.

Eleven letters of support are from elected officials: Congress of the

United States, House of Representatives, 23rd Congressional District

Florida, Congressman Alcee L. Hastings; The Florida Senate, 34th

District, Senator Nan Rich; Florida House of Representatives, 96th

District, Representative Ari Abraham Porth; Florida House of

Representatives, 97th District, Representative Martin David Kiar; Florida

House of Representatives, 94th District, Representative Hazelle P. Rogers,

Democratic Deputy Whip; Florida House of Representatives 98th District,

Representative Franklin Sands; Florida House of Representatives, 92nd

District, Representative Gwyndolen Clarke-Reed; Florida House of

Representatives, 99th District, Representative Elaine J. Schwartz; City of

Fort Lauderdale District III Commissioner Bobby B. DuBose; and City of

Lauderdale Lakes, Office of the Mayor and City Commission,

Commissioner Eric L. Haynes. The letters mainly focused on Odyssey‟s

commitment to developing stronger relationships with minority and other

underserved communities in Broward County. Representative Ronald A.

Brisé, Florida House of Representatives, 97th District (part of Miami-Dade

County) also submitted a letter of support. Other letters highlight the

applicant‟s specialized programs such as CareBeyond for dementia,

cardiac, cancer, and COPD patients; and indicate that as a for profit

corporate citizen, Odyssey would pay state corporate income and sales

taxes.

Odyssey also has the support of Naushira Pandya M.D., CMD, Chair and

Associate Professor, Department of Geriatrics at Nova Southeastern

University. Dr. Pandya cites Odyssey‟s commitment to contribute

financially to the Geriatric Program to endow a fellowship program and

the proposed partnership (copy of the affiliation agreement is in CON

#10086 Application Appendix M).


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Nancy Botero, Executive Director of the Broward College Foundation,

indicates that Odyssey‟s interest in developing a partnership with the

college is most appreciated. Broward College Foundation‟s proposal for

Odyssey‟s consideration was included in Appendix N of the application.

The proposal is for $75,000 over three years for Broward College to

establish a course of study in hospice, end-of-life and palliative care,

train and develop faculty and create student scholarship/internship

opportunities. Odyssey would provide $25,000 for course and faculty

development in year one and $25,000 per year two and three for three

scholarships for RN to BSN students and for continued faculty

development.

The applicant has nine letters of support from Broward County minority

residents (Haitian, Hispanic, African-American, and Caribbean

American). These letters focus on Odyssey‟s commitment to expanding

hospice services, education, and outreach to the community especially

the various minority communities in Broward County. They do not

document or allege that hospice care to these populations is not available

or accessible.

The remaining 18 letters are from providers and referrers outside the

hospice service area.

C. PROJECT SUMMARY

Compassionate Care Hospice of Miami Dade, Inc. (CON #10083)

proposes the establishment of a new hospice program in Hospice Service

Area 10, Broward County. Compassionate Care Hospice was founded in

1993. Over the past 17 years Compassionate Care Hospice has

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

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

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

and Wisconsin. Compassionate Care Hospice has been approved to

establish a hospice program in Subdistrict 6B.

The applicant is proposing total project costs of $131,800 with year one

operating costs of $1,233,571 and year two costs of $3,467,922.


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Schedule C includes the following conditions:

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

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

this CON application.

Compassionate Care will provide all the required components of hospice

care, and meet all Medicare Conditions of Participation, and Florida

hospice licensure requirements, including the provision of all levels of

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

all types of patients (cancer, non-cancer, Alzheimer‟s, COPD, elderly,

young adult, pediatric) without regard to race, ethnicity, gender, age,

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

other discriminating factor.

1. Compassionate Care Florida will implement a concentrated

outreach program for ALFs and will visit all licensed ALF providers,

regardless of size, in the first year of operation, and will provide

educational information to such ALFs in the language suitable for

the facility staff and residents. Compliance will be measured by a

signed declaratory statement submitted to the Agency.

2. Compassionate Care Florida will implement its Hispanic Outreach

Program immediately upon licensure. Compliance will be

measured by a signed declaratory statement submitted to the

Agency.

3. At least 25 percent of all interdisciplinary team members in

District 10 consisting of physicians, registered nurses, home

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

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

a signed declaratory statement submitted to the Agency.

4. Compassionate Care Florida will work with local Hispanic

organizations including Hispanic Unity Florida, to recruit, train

and employ Hispanic personnel. Compliance will be measured by

a signed declaratory statement submitted to the Agency.

5. Compassionate Care Florida will implement its Cardiac

Connections program in Broward County, District 10 within year

one of operation. Compliance will be measured by a signed

declaratory statement submitted to the Agency.


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6. Compassionate Care Florida has conditioned approval of this

application on the provision it will provide one FTE life

enhancement specialist. Compliance will be measured by a signed

declaratory statement submitted to the Agency.

7. Compassionate Care Florida has conditioned approval of this

application on the provision it will provide one FTE homemaker.

Compliance will be measured by a signed declaratory statement

submitted to the Agency.

8. Compassionate Care Florida will become accredited by the National

Institute for Jewish Hospice within year one of operation.

Compliance will be measured by a signed declaratory statement

submitted to the Agency.

9. Compassionate Care Florida will partner with Nova Southeastern

University‟s College of Allied Health and Nursing to provide a

clinical rotation site to matriculating students seeing a degree in

nursing. Compliance will be measured by a signed declaratory

statement submitted to the Agency.

10. Compassionate Care Florida will condition approval of this

application on the provision it will become accredited by CHAP

upon certification. Compliance will be measured by submission of

accreditation certificate to the Agency.

11. Compassionate Care Hospice Group, Ltd. will implement its

Pathways to Compassion program immediately upon licensure of

Compassionate Care Hospice of Florida, which will be made

available to all eligible Broward County residents. Compliance will

be measured by a signed declaratory statement submitted to the

Agency.

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

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

week. Compliance will be measured by a signed declaratory

statement submitted to the Agency.


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Douglas Gardens of Broward, Inc. (CON #10084) proposes the

establishment of a new hospice program in Hospice Service Area 10,

Broward County. Douglas Gardens of Broward, Inc. is a new entity

formed for the sole purpose of establishing a hospice program in Service

Area 10. Through the collaboration of its share holders, Seasons

Healthcare Management and Miami Jewish Health Systems, there will be

a change of ownership for Douglas Gardens Hospice, Inc., to become

Seasons Hospice and Palliative Care of Southern Florida, Inc.

The proposed total project cost is $802,715 with year one operating costs

of $3,450,500 and year two costs of $5,712,200. The applicant agrees to

condition award of the CON upon providing the following:

1. Douglas Gardens will establish more than one location within

Broward County, with the number and timing of opening based

upon priority determined with input from the key residents in each

of the 31 cities in the county, identified in the Circle of Care

Community Link Program. By the end of the second year of

operations Douglas Gardens proposes to have more than one office

in the county.

2. Douglas Gardens commits to annually allocate funds based on

revenues. In year one, they will allocate and distribute $93,000 to

Circle of Care Community Link. The funds will be distributed as a

$3,000 outreach grant to each of the 31 cities‟ Circle of Care

Community Link.

3. Douglas Gardens commits to provide $15,000 (one time) to extend

the partnership with the National Hospice and Palliative Care

Organization. The applicant will participate in a Quality Partner

performance improvement program that gives hospice providers

tools to monitor and assess both clinical and non-clinical areas to

determine areas in need of improvement.

4. Douglas Gardens commits to seek and maintain accreditation by

The Joint Commission. The applicant will provide a copy of the

accreditation to the Agency and to the Department of Elder Affairs.

5. Douglas Gardens commits to publish at least one edition of both

the Seasons Hospice & Palliative Care News letter and the

PharmSmart news letter. The applicant will provided a copy of

each issue to the Agency and to the Department of Elder Affairs.


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6. Douglas Gardens commits to become a CEU provider for licensed

nurses and licensed social workers by the end of the second year of

operations. The applicant will provide the Agency with a copy of

the Education Provider Number from the Florida Board of Nursing

as well The Florida Board of Clinical Social Work, Marriage and

Family Therapy, and Mental Health Counseling and schedule of

courses, days and times.

7. Douglas Gardens commits to voluntary submission of county level

data to the Department of Elder Affairs and to The Agency, by the

end of the second year of operations, on admissions by age,

disease categories, place of admission, time to assessment, time to

enrollment, length of stay and visits.

8. Douglas Gardens commits to 2.5 percent of admissions for

uncompensated care to be confirmed by an annual report to the

Department of Elder Affairs.

9. Douglas Gardens commits to provide palliative radiation as

prescribed in the plan of care which will be measured by an annual

report to the Agency.

10. Douglas Gardens commits to provide palliative chemotherapy as

prescribed in the plan of care which will be measured by an annual

report to the Agency.

11. Douglas Gardens commits to provide ventilator-dependant in-home

care to hospice patients as prescribed in the plan of care which will

be reported annually to the Agency.

12. Douglas Gardens commits to provide a program designed for

terminally ill children called Kangaroo Kids.

13. Douglas Gardens commits to Kangaroo Camp at a Florida Resort

for terminally ill children and families by the end of the second

year of operations. The applicant will send notification to the

Agency for reporting purposes.

14. Douglas Gardens commits to implement the program a Touch for

All Seasons-Alzheimer‟s Disease and other dementia. Compliance

will be affirmed through an annual report to the Agency.


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15. Douglas Gardens commits to implement the program Partnership

in Caring, a program for the education of nursing home staff.

Compliance will be affirmed through an annual report to the

Agency documenting the facilities participating in the program as

well as the number of staff educated at her facility.

16. Douglas Gardens commits to provide a music therapy program.

Compliance will be affirmed through an annual report to the

Agency documenting the number of patients who received music

therapy and the number of music therapy visits delivered.

17. Douglas Gardens commits to employ one or more dieticians (based

on staffing ratios) which will be reported to the Agency annually.

18. Douglas Gardens commits to implement and maintain electronic

medical records.

19. Douglas Gardens commits to a call center staffed with Seasons

employees 24 hours a day, seven days a week. The applicant

states that Seasons operates its own call center, fully integrated

with electronic medical record for real time responses-tracking,

and assignment of assessments. Douglas Gardens expects the

new hospice program in Service Area 10 will be fully integrated into

the Seasons system.

Hospice of Palm Beach County, Inc. (CON #10085) proposes to

establish a hospice program in Hospice Service Area 10, Broward

County. Hospice of Palm Beach County is owned by Spectrum Health,

Inc., a not-for-profit corporation organized to support the programs,

services, activities and interests of Hospice of Palm Beach County,

Hospice of Palm Beach County Foundation, and The Medical Store.

Hospice of Palm Beach County was founded in February 1978 as a not-

for-profit hospice agency. Hospice of Palm Beach County has a 36-bed

inpatient hospice in Hospice Service Area 9C.





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1. Hospice of Palm Beach County commits to establish a new

foundation for Broward County to meet the needs of Broward

County residents and to provide $1 million in initial funding for its

establishment. These funds will go towards building a permanent

foundation that will cover the same broad group of programs that

the applicant‟s Hospice of Palm Beach County Foundation covers

today. Compliance will be documented by providing a declaratory

statement to the Agency annually providing the number of

programs and services provided to families in need.

2. Hospice of Palm Beach County commits to provide a minimum of

$250,000 per year earmarked for complex palliative interventions

such as radiation therapy, chemotherapy, high cost medications,

blood transfusions, and intravenous nutrition. Compliance with

this condition will be documented by an annual affirmative

statement to the Agency.

3. Hospice of Palm Beach County commits to provide two full-time

salaried positions, with bilingual requirement (Spanish and

Creole). Team members will be responsible for the development,

implementation, coordination and evaluation of programs to

increase community knowledge and access to the hospice services.

Compliance will be documented by annual submission of seminars

and programs that were offered and a declaratory statement to the

Agency.

4. Hospice of Palm Beach County commits to recruit bilingual

volunteers. Patients‟ demographic information, including other

languages spoken, is collected so that the most compatible

volunteer can be assigned to fill each patient‟s visiting request.

During the past six months, a targeted bilingual recruiting

program in Palm Beach County resulted in 38 new volunteers

fluent in English and Spanish or Creole. Compliance will be

documented by annual submission of a records summary to the

Agency.


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5. Hospice of Palm Beach County commits to establishing a new Vigil

Volunteer Program equipped with a team of specifically trained

volunteers available to respond on short notice to provide presence

during the last few hours of life to patients without family support

or patients and families who need additional support. Vigil

volunteers also provided support to family members who need a

break from the bedside of their loved ones during the dying

process. Compliance will be documented by submission of records

summary kept by the Hospice of Palm Beach County volunteer

coordinator to the Agency.

6. Hospice of Palm Beach County commits to offer a separate

children‟s camp to the Broward Community. Camp SeaStar,

Hospice of Palm Beach County‟s annual three-day, two-night camp

for bereaved children is a unique and special opportunity for

volunteers. These retreats provide enhancement to traditional

bereavement services, especially for those children experiencing

problematic grief. Compliance will be documented by annual

submission of camp dates to the Agency.

7. Hospice of Palm Beach County commits to provide bereavement

services beyond the 13 months required by law. Hospice of Palm

Beach County will not limit these services to the families of the

deceased and will offer bereavement counseling to the community-

at-large. Hospice of Palm Beach County will also establish grief

support programs to workplaces that have experienced traumatic

or multiple losses. Compliance will be documented by submission

of bereavement programs that were offered and a declaratory


8. Hospice of Palm Beach County commits to provide music therapy,

massage, aromatherapy, craniosacral therapy, relaxation training,

and Reiki beyond the Medicaid benefit. These measures will

enhance the physical, emotional, and spiritual wellbeing of Hospice

of Palm Beach County‟s patients and families. Compliance will be

documented by an annual declaratory statement to the Agency.

9. Hospice of Palm Beach County commits to expand Joint

Commission accreditation into Broward County upon eligibility to

do so. Compliance will be documented by an annual declaratory


10. Hospice of Palm Beach County commits to provide all services

required by state and federal law and regulations.


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Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON # 10086) proposes to establish a

hospice program in Hospice Service Area 10, Broward County. The

applicant states that its parent company is Odyssey HealthCare. The

parent is stated to have 90 Medicare-certified hospice programs in 30

states. Odyssey is licensed in Florida and serves three hospice service

areas: Service Area 11 (Miami-Dade and Monroe Counties), Service Area

4B (Volusia and Flagler Counties) and as of January 1, 2010 Service

Area 3B (Marion County).1




Specific Broward County Initiatives

1. Odyssey‟s new program will be licensed within six to 12 months of

obtaining authorization to establish a new program with Medicare

certification to follow within one month.

2. Odyssey will implement the “Care Beyond” Program. This will be

measured via a signed declaratory statement. Odyssey will launch

two of its existing CareBeyond Programs in year one (CareBeyond

Cardiac in the first six months, followed by CareBeyond Cancer in

the second two months) to be followed by the two other existing

Care Beyond programs in year two.

3. Odyssey commits to provide $50,000 per year for a minimum of

three years to Nova Southeastern University to support the

development of Nova Southeastern University‟s Geriatric Education

Center. Odyssey has entered into an affiliation agreement with

Nova Southeastern University to engage in research on end-of-life

care and further developing best practice protocols/services for

end-of-life. The affiliation agreement between these two

organizations will enhance the education, training and research

opportunities for Nova Southern University students enrolled in

the geriatrics department.

1 Odyssey HealthCare of Marion County, Inc. became licensee for hospice Service Areas 4B & 11

effective November 1, 2009 and added Marion County to its license effective January 1, 2010. Odyssey had previously operated as Odyssey HealthCare.


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4. Odyssey commits to provide $75,000 over three years to Broward

College to establish a course of study in hospice, end-of-life and

palliative care, train and develop faculty and create student

scholarship/internship opportunities. Broward College is Broward

County‟s principle provider of post-secondary education with a

significant presence in providing community-based health care

education to the local minority populations. Broward County

brings a strong workforce initiative to Broward County‟s health

care providers as 80 percent of students who graduate from

Broward College‟s health programs find employment locally.

5. Odyssey will implement its Performance Improvement (PI) plan

including the following assessments: pain management, family

satisfaction, employee satisfaction, and referral source satisfaction.

Compliance will be measured via a signed declaratory statement.

6. Odyssey commits to comply with all Agency reporting

requirements, including semi-annual utilization reports. Odyssey

includes as part of this condition voluntary reporting of the “Family

Evaluation of Hospice Care (FEHC) Satisfaction Survey.”

7. Odyssey commits to make available a range of non-covered

supplementary therapies such as but not limited to: pet, music,

massage, aroma, and laugh therapies as well as other holistic

treatments. Compliance will be measured via a signed declaratory

statement by the applicant, which may be supported via a review

of patient medical records.

8. Odyssey will establish a local ethics committee within the first year

of operation. Compliance will be measured via submission of the

names and other relevant information of the ethics committee

members and the related schedule of meetings to the Agency.

9. Odyssey will establish a local medical advisory committee within

the first year of operations. Compliance will be measured via a

submission of names and other relevant information of the medical

advisory committee members and the related schedule of meetings

to the Agency.


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10. Odyssey will provide educational programs, including but not

limited to, in-service training (components of Odyssey University)

resources to the community, including nursing homes, assisted

living facilities, and the Council on Aging. In-service training and

continuing medical education will also be offered to physicians,

registered nurses, social workers, administrators and other staff

that would benefit from an increased knowledge of hospice care

and services. In addition, the Odyssey will host at least one

seminar annually during the first two years of operation for clergy

and community faith leaders (The clergy end-of-life education

program) to enhance spiritual support for hospice patients in the

district. Compliance will be measured via a signed declaratory

statement. These educational programs are in addition to the

regular educational programs routinely offered by Odyssey‟s

community education representatives in local hospitals, nursing

homes, and assisted living facilities for patients, families, and

facility staff.

11. Odyssey will provide patients, family members and referral sources

with information of services provided by the Dream Foundation.


12. Odyssey commits to 0.5 FTE the first year of operation for

development efforts regarding community bereavement programs

in the community. The bereavement programs will be broadly

based to extend beyond the families of patients admitted to

Odyssey HealthCare. These programs will be an extension of the

programs currently offered in the hospice service area. Odyssey

will provide bilingual staff to provide bereavement services to the

minority populations of Broward County, including African

American, Hispanic, Brazilian, Haitian, and Caribbean children.

At a minimum, one bereavement group consisting of approximately

eight sessions will be offered by the end of the first year of

operation. As the bereavement client census increases after one

year, full-time staff will be employed. Compliance will be measured

via a signed declaratory statement.

13. Odyssey commits to the provision of programs for the African

American, Hispanic, Brazilian, Haitian, Caribbean and other

minority populations of Broward County which will include

support from and involvement of bilingual staff, translated

literature, training on cultural differences and competencies and

flexible programming to meet these unique needs. Hospice staffing

will reflect the racial and ethical mix of local community served.



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14. Odyssey commits to have a minimum staff of at least three

community education representatives, expanding community

awareness of hospice services and educating local medical staff,

community leaders, and potential hospice patients as to the

benefits of and availability of hospice care. Compliance will be

measured via submission of an annual report confirming that at

least three CER staff members are employed at the proposed new

service and active in the local community. Additionally, if

approved, Odyssey will provide education, training and assistance

in development of respite care policies, procedures and protocols to

nursing homes.

15. Odyssey commits to simultaneously establishing two offices in

Broward County: one office in the I-75/southwest area of Broward

County and the second along the I-95 corridor in the

central/northeast section of Broward County. Multiple locations

benefit both patients and staff by enhancing geographic access.

16. Odyssey commits to become accredited by the Joint Commission

and the National Institute for Jewish Hospice by the end of its

second year of operation. Odyssey has chosen to commit to

accreditation to demonstrate its commitment to quality services as

well as its commitment to providing culturally sensitive hospice

services. Accreditation by the National Institute for Jewish

Hospice will demonstrate to the Jewish population of Broward

County that Odyssey can and will meet their end-of-life needs in

accordance with Jewish tradition.

17. Odyssey commits to the Medical Director being board-certified in

hospice and palliative care medicine or applying for board

certification within five years of employment to further

demonstrate its commitment to clinical excellence and

commitment to the advancement of hospice services and the

continued improvement of hospice service quality.

18. Odyssey commits to sponsoring two to four education seminars per

year for physician, clergy, and administrators of skilled nursing/

long-term care facilities and assisted living facilities (ALFs). The

focus of these seminars is to provide continuous medical education

to the health care professionals, educate the local health care

community on the provision services within ALFs and other long-

term care facilities.


19

Conditions of Participation as required by all Medicare-Certified Hospice

Providers:

19. Odyssey will provide hospice services 24 hours a day, seven days a

week including weekend care as indicated by the patient‟s medical

condition. Odyssey provides a triage and on-call programs. An on-

call nursing team is available after hours and on weekends for

triage, visits and phone consultation. Other specialists, such as

nutritionist and physical, speech, or occupational therapies are

part of Odyssey‟s core services and are added to a patient‟s team

as needed.

20. Odyssey commits to having every patient assessed by the

interdisciplinary team upon admission to the hospice. Power week

is Odyssey‟s version of each disciplines‟ assessment process. Each

patient is visited by each discipline within the first five days from

admission day (rather than Medicare‟s required 14 days). This

process allows for the care team to fully assess the patient and

contribute to the comprehensive care plan.

21. Odyssey will provide routine care. Odyssey routine care provides

for daily contact with the patient and also includes the “tuck in”

process to insure that all patients have everything needed prior to

a weekend or holiday. Both of these measures are provided so that

patients‟ needs can be anticipated and emergencies can be

avoided.

22. Odyssey will provide education services. Medicare‟s conditions of

participation require that hospice programs provide education (for

non-hospice staff) to skilled nursing facility staff that care for

hospice residents residing in their facilities. Odyssey employs

community education representatives, clinical liaisons and

community liaisons for education to the medical community at

large.

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

to everyone requesting them and therefore the Agency would not place

conditions on a program to provide legally required services such as

palliative radiation and chemotherapy and care to the indigent and charity

patients. The applicants’ proposed conditions are as they stated.

However, Section 408.043 (4) Florida Statutes states that “Accreditation by

any private organization may not be a requirement for the issuance or

maintenance of a certificate of need under ss. 408.031-408.045.” Also,

many of these conditions are required hospice services and as such would

not require condition compliance reports.


20

Should a project be approved, the applicant’s proposed conditions would be

reported in the annual condition compliance report as required by Rule

59C-1.013 (3) Florida Administrative Code. Section 408.606 (5) Florida

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

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

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

unless the applicant can demonstrate that good cause exists for the

applicant’s failure to meet such condition”.

D. REVIEW PROCEDURE

The evaluation process is structured by the certificate of need review

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

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

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

goals represent desirable outcomes to be attained by successful

applicants who demonstrate an overall compliance with the criteria.

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

successfully is conducted by evaluating the responses provided in the

application, and independent information gathered by the reviewer.

Applications are analyzed to identify various strengths and weaknesses

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

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

applications are comparatively reviewed to determine which applicant

best meets the review criteria.

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

amendments once an application has been deemed complete. The

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

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

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

certification of the applicant.

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

application in its entirety with consultation from financial analyst,

Everett (Butch) Broussard, who evaluated the financial data.


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E. CONFORMITY OF PROJECT WITH REVIEW CRITERIA

The following indicates the level of conformity of the proposed projects

with the criteria found in Florida Statutes, Sections 408.035 and

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

59C-2, Florida Administrative Code.

1. Fixed Need Pool

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

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

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

April 2, 2010, a hospice program net need of one was published for

Service Area 10 for the July 2011 Hospice Planning Horizon. Service

Area 10 is currently served by Hospice by the Sea, Inc., HospiceCare of

Southeast Florida, Inc., Hospice of Gold Coast Home Health Services,

VITAS Healthcare Corporation of Florida, and Catholic Hospice, Inc.

Each co-batched applicant is applying in response to published need for

a hospice program in Hospice Service Area 10, Broward County.

However, all applicants provide additional arguments in support of need

for their projects as discussed below.

Below are population estimates for Broward County, HSA 10, from July

2010 to July 2015.

Population Estimates for Hospice Service Area 10 and State

July 2010 - July 2015 Age Change

Group 2010 2015 Number Percent

Under 65 1,548,930 1,623,158 74,228 4.8%

65+ 263,024 297,516 34,492 13.1%

HSA 10 Total 1,811,954 1,920,674 108,720 6.0%

Under 65 15,984,971 17,021,995 1,037,024 6.5%

65+ 3,397,626 4,011,033 612,407 18.02%

State Total 19,382,597 21,033,028 1,649,431 8.5% Source: AHCA Population Estimates July 2010 - July 2015, published September 2008.

Compassionate Care Hospice of Florida, Inc. (CON #10083) states

that in addition to the published fixed need pool determination, it has

undertaken its own needs assessment and has identified specific

terminally ill populations which are in need of hospice services and are

significantly underserved. These underserved populations are listed as:

terminally-ill patients of small assisted living facilities, Hispanic


22

residents, and terminally-ill non-cancer and cancer patients of all age

cohorts. Compassionate Care states it has a plan to address each of

these population groups and provides qualitative analysis as well as

interviews from local health care providers to support its claims.

Compassionate Care states that smaller ALFs are a main driver of the

lower hospice penetration rate in Broward County. Broward County has

299 ALFs with 8,611 licensed beds. Of the 299, 216 of them have 30

licensed beds for fewer and 185 of them are licensed for 10 or fewer beds.

Smaller ALFs with 10 or fewer beds make up 61.8 percent (185/299) of

all ALFs in Broward County. Compassionate states that there seems to

be a lack of education and outreach in the small individual ALFs;

existing providers appear not be focusing on reaching out to these small

facilities. Compassionate states this is largely due to the number of

potential residents touched on an educational and support visit are

disproportionately low compared to larger facilities (61 percent of the

facilities only represent 13 percent of the beds). Therefore,

Compassionate Care states the existing hospice providers are focusing on

the larger institutions (39 percent of the facilities with 87 percent of the

beds) where it is easier and more economical to conduct education,

outreach, and to provide care.

Based on interviews and community feedback, Compassionate Care

states many of the small ALFs have a fundamental misunderstanding

about hospice and generally do not understand that the resident does

not lose other funding sources by choosing hospice and opting for

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

facility. Compassionate Care has conditioned approval of this

application on the provision that it will implement a concentrated

outreach program for ALFs and will visit all licensed ALF providers in the

first year of operation. Compassionate Care indicates that it has received

several letters of support from smaller HSA 10 ALFs and refers the

reviewer to Tab V of the application. Review of these eight letters show

the six stand-alone ALFs range in size from 110 to 240 beds. The other

ALF letters are from facilities that also have skilled nursing beds; Park

Summit with 35 SNF and 72 ALF beds and The Forum at Deer Creek

with 60 SNF and 65 ALF beds.

The applicant states that Hispanics are the largest ethnic minority

population in HSA 10 yet they are the least likely cohort to utilize hospice

services. In Broward County, the applicant states that Hispanics

comprise 24.3 percent of the total population increasing up to 28.5

percent by 2014. There is a greater concentration of Hispanic residents

in Miramar which is 40 percent Hispanic and projected to increase to

43.8 percent by 2014. The applicant refers to a study published by


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Karen Anderson, et. al. in The Journal of Pain titled, Racial and Ethnic

Disparities in Pain: Causes and Consequences of Unequal Care, which

found “persistence of racial and ethnic disparities in acute, chronic

cancer and palliative pain across the lifespan and treatment settings,

with minorities receiving lesser quality pain care than non-Hispanic

white.” The study states, “Minority patients are less likely than non-

minority patients to enroll in hospice care. Specifically, less than six

percent of patients in the United States enrolled in hospice care are

Hispanic.”2 The applicant states that one contributing factor for such

low utilization is that Hispanic patients and providers have limited

knowledge of hospice programs and goals. Compassionate Care also

states that cultural attitudes and beliefs surrounding end-of-life care

may adversely affect hospice enrollment.

The applicant states that there was a 96 percent increase (from 716

deaths in 1999 to 1,403 in 2008) in Hispanic deaths in Broward County

during the past 10 years and there was a nearly 15 percent decrease in

non-Hispanic deaths. In the 65 and older age cohort from 1999 to 2008,

Hispanic deaths in Broward County increased from 455 to 922 or by 103

percent whereas deaths amongst their non-Hispanic counterparts

decreased from 12,382 to 9,971 or by nearly 20 percent. Between 2006

and 2008, Hispanic deaths increased 11 percent from 1,263 to 1,403

while non-Hispanic deaths decreased by 3.5 percent from 13,711 to

13,2263. Compassionate Care states that based on the 2009 Hospice

Annual Report from the Florida Department of Elder Affairs, 7.6 percent

of hospice admissions in Service Area 10 are Hispanic while Hispanics

account for 9.6 percent of deaths in Broward County. The applicant

furthers its argument that Hispanics are underserved by examining the

Broward County hospital discharges to hospice. The applicant states

that in 2009, 2.7 percent (4,210/157,694) of all non-Hispanic discharges

from Broward County hospitals were to hospice. During the same time

period, only 1.7 percent (422/24,579) of Hispanic hospital discharges

were transferred to hospice care. Compassionate Care states that had

Hispanics had equal hospice discharge rates as non-Hispanics in the

hospital setting there would have been at least 148 additional Hispanic

admissions4.

2 The National Hospice and Palliative Care Organization‟s NPHCO Facts and Figures on Hospice Care in America, 2009 edition indicates that 5.6 percent of the United States‟ total hospice admissions were Hispanic in CY 2008 up from 5.1 percent in CY 2007. This publication indicates that approximately 1.45 million patients received hospice services in 2008, up from 1.4 million in 2007. 3 Broward County Resident Deaths, Hispanic versus Non-Hispanic Deaths 2006-2008; Florida Office of Vital Statistics and NHA Analysis; CON Application 10083, page 16. 4 Broward County Hospital Discharges, Hispanic versus Non-Hispanic CY 2009; AHCA Inpatient data tapes and NHA analysis; CON Application 10083, page 17.


24

Compassionate Care states it has the skill set to admit, manage, and

treat Hispanic patients and will enhance overall hospice penetration

among the Hispanic terminally-ill residents. Compassionate Care states

that it hires Spanish-speaking staff including nurses, aides, chaplains

and others so that the patient and their family are comforted rather than

feeling anxiety and distress associated with an inability to speak the

language fluently. The applicant states that it commits to serving the

Hispanic terminally-ill patients of HSA 10 and has crafted a Hispanic

Outreach Plan to ensure it will enhance hospice penetration rates among

terminally-ill Hispanic population and will also partner with Hispanic

Unity of Florida, Inc. to host health education events throughout the

community5.

Compassionate Care states that the greatest projected need for hospice

services in Broward County falls within the non-cancer patient

population and of the 1,849 projected gap in hospice admissions, 54.6

percent will be non-cancer admissions. Of the 1,010 non-cancer

admissions, 791 are forecasted to be in the 65 and older age cohort while

the remaining 291 will be under 65.

The applicant states that Compassionate Care has extensive experience

caring for the hospice needs of non-cancer terminally ill patients.

Through its Cardiac Connections heart failure home management

program, it can enhance access to hospice care for individuals suffering

from heart disease related illnesses. The applicant states that there are

3,858 heart disease related deaths in Broward County which represents

about 26.4 percent of total annual deaths and 13 percent of all Broward

County hospice admissions. According the applicant, Cardiac

Connections will help Broward County residents by providing clinical

leadership, team experts, unmatched solutions and a specialized cardiac

formulary. The applicant states that patients in this program experience

significantly reduced or eliminated visits to the emergency room and

hospitalization.

Compassionate Care provides an analysis of the need projections and

indicates that cancer patients under 65 years of age and age 65 and

older are underserved and 839 of the 1,849 projected gap in hospice

admissions will be cancer admissions. With nearly 3,400 cancer related

deaths in Broward County annually, 79.3 percent obtain end-of-life care.

5 Hispanic Unity of Florida, Inc. is a non-profit United Way organization that serves the immigrant population of Broward County and whose mission is to empower Hispanic and other members of the community to become self-sufficient and lead productive lives. Source: Josie Bacallao, Hispanic Unity of Florida, President & CEO support letter for CON Application #10085 Hospice of Palm Beach County.


25

The applicant states that while cancer penetration rates are much higher

than the non-cancer penetration rates, there is a much greater disparity

between the HSA 10 rates compared to state-wide cancer penetration

rate. The applicant states the existing providers are not focused on

reaching cancer patients and that their focus on non-cancer patients has

contributed to the low penetration rate among cancer patients.

Compassionate Care asserts that it provides care for all patients,

including cancers in all forms and that HSA 10 has a tremendous need

for both cancer and non-cancer accessibility and therefore it will make

every effort to implement cancer and non-cancer disease focused

programs.

The applicant states that through meetings with rabbis and members of

the community, the Jewish population as being underserved when it

comes to formal end-of-life care. The applicant states that even though

there is an existing provider in HSA 10 that is accredited by the National

Institute for Jewish Hospice, there is still a general lack of access to

appropriate and meaningful Jewish hospice services. The applicant

states that Compassionate Care‟s Jewish Hospice Program is already

accredited by the National Institute for Jewish Hospice (NIJH). It is

Compassionate Care‟s intent to similarly accredit the Broward County

hospice and reach to the Jewish Community to educate and enhance

market penetration. It is noted that while the applicant has letters of

support from rabbis in HSA 10, those letters did not explicitly state that

the current provider was not meeting their needs.

The analysis culminates in Compassionate Care stating it has identified,

quantified, and qualitatively discussed the underserved groups in

Broward County, HSA 10. Based on the above assessment, the applicant

anticipates 170 admits in year one (2012) and 456 admits in year two

(2013).

Douglas Gardens of Broward County, Inc. (CON #10084) states that its

parent company, Miami Jewish Health Systems recognized the need to

expand hospice care throughout the communities they serve; so Miami

Jewish Health Systems sought out a partner to manage and grow the

hospice program. The applicant states that the innovative programs and

high quality standards exemplified by Seasons Healthcare Management,

as well as a mission driven philosophy, made them a perfect choice to

advance this service. The applicant states that the collaboration between

the two organizations produced advantages for assuring uniform delivery

of high quality end-of life care: a client centered approach to care; the

delivery of a complex mix of both home and community based services;

integration with existing institutional care providers, including those of

Miami Jewish Health Systems as well as within the community; opens a


26

broad base of community support that results in the offering of services;

an advocate for the poor, near poor and ethnic minorities; and a clear

identity with the elderly. The applicant states that as one organization,

uniform services are important to reducing barriers to care and this

collaboration was necessary to address the lack of access to hospice care

in HSA 10. The applicant states it will ensure uniform access by

extending those services provided in Miami-Dade and Monroe Counties

to Broward County.

The applicant begins its analysis by comparing Service Area 10 need to

that of Citrus County, Service Area 3C, which does not have a gap

between forecasted admissions and current enrollment. The applicant

states that based on the number of area offices that are located

throughout Service Area 3C, those hospices are more accessible to the

population making end-of-life care more personal and local thus

fostering a sense of community. In comparison, the applicant states that

HSA 10 hospices lack the sense of community because the ratio of area

offices to the population is far below that of Citrus County. The

applicant states that without personal and local involvement from local

people, enrollment in hospice will fall below areas where people feel

connected to the process. Douglas Gardens states that the wide gap

between future and current hospice admissions can be described as a

failure to meet the need on a local level. Douglas Gardens asserts that

the premise of this proposal is based on the knowledge that community

identity and relationships fostered through presence, commitment and

cooperation lead to hospice enrollments. In contrast, reliance on

corporate identity, lack of physical presence to create a focus for care,

and absent integration with existing community and health services,

results in the gap between hospice forecasted and actual enrollments.

The applicant states that many of the usual factors cited to explain

divergence cannot be used to account for the wide gap in admissions

experienced in Broward County. The applicant states that neither

specific disease processes nor in-hospital deaths for certain ethnic

groups are factors contributing to the gap in hospice enrollments in

Broward County. Douglas Gardens provides a comparison of CY 2008

in-hospital deaths reported for Broward County residents and the state.

During CY 2008, 7,368 of 14,629 or 50 percent of Broward County

resident deaths were in-hospital compared to the state average of 56

percent (96,082/170,473). The applicant states that overall, HSA 10

providers are doing a good job at reaching people in hospitals, having

them discharged to hospice care.


27

The applicant states that the elderly population age 65 and over has the

greatest unmet need within the planning area and many of these

individuals are residing in assisted living facilities or skilled nursing

facilities. Douglas Gardens states that 2009 annual hospice data

reported to the Department of Elder Affairs shows that Broward County

hospice programs have proportionately fewer nursing home patient days

of care (17.5 percent) than the average for the state, at 23.8 percent. The

applicant states that its provision of hospice services to nursing home

patients in District 11 was reported as 33.8 percent for 20096; and

Season‟s hospice services to nursing home patients around the country

were 33.8 percent for the 12-month period ending April 30, 2001.

Therefore the applicant states that Douglas Gardens and Seasons are

able to reach more nursing home residents in the normal course of

operations and will be able to improve service to nursing home residents

throughout the service area, building on existing relationships in

Broward County.

The applicant presents an analysis of HSA 10 providing hospice need

within individual communities of Broward County7. This analysis shows

the Broward County CY 2008 resident deaths by cities, the expected

hospice (state actual) penetration rate (P Value=63.74%) and applies the

actual Broward hospice penetration rate (P Value=56.66%) to arrive at

the hospice need per city. The applicant credits the success of other

HSA‟s like Citrus County SA 3C, where it contends hospice becomes a

community partner in treating the individual within his or her

community, among family and friends, with employees and volunteers

from within the community. Douglas Gardens states that through its

analysis, it has created an entirely new program for the explicit purpose

of remedying the gap between forecasted and actual hospice enrollment.

This program is called Circle of Care Community Link8 and will be the

initial link into each community within HSA 10 for the purpose of

determining where physical presence should be located, where

information and referral sources need to be cultivated, and where

employees and volunteers will come. Douglas Gardens provides a list of

6 2009 Patient Days and Percent of Total Hospice Days by Location of Service Hospice Programs Operating in Broward County, Table 1-7; CON Application #10084, Need Analysis page,1-19. 7 Hospice Need Within Individual communities of Broward County, Table 1-15; CON Application #10084, Need Analysis, page 1-32. 8 Circle of Care Community Link objectives are to facilitate the acceptance of hospice care as an important and vital service among all health and human services within a community; to create community awareness and ownership of end-of-life care; to establish a reliable, “can do” partner in finding the right fit and mix of services for each person within the community; and to ensure an ever-present, ongoing link to the plethora of services that comprise aging and end-of-life decisions to create peace of mind, solace, and living the slogan, “Honoring Life-Offering Hope”. CON Application #10084, Need Analysis, pages 1-33, 1-34 and 1-36.


28

locations/organizations in 31 Broward County cities that its Community

Link will use to establish a point of contact for developing out-reach to

increase hospice enrollments. The applicant states that this approach

assures that all persons recognize a provider who is there to help and

can be counted upon to deliver services when needed.

Douglas Gardens concludes its need analysis with a forecast for hospice

admissions. The applicant states that by using a conservative estimate

based on the Florida experience, it projects that it will serve 202 hospice

admissions in the first year of operation with 11,757 patient days, an

average length of stay of 58 days, and a two percent market share. Year

two of operations will consist of 358 hospice admissions, 23,935 patient

days, an average length of stay of 67 days, and a 3.5 percent market

share.

Hospice of Palm Beach County, Inc. (CON #10085) indicates that in

addition to the fixed need pool showing the need for another program, it

evaluated a number of aspects of Hospice Service Area 10 to address the

underserved segments of the population including: demographic trends,

historical utilization of hospice services, potential to increase penetration

rates, special needs populations and projected growth in hospice

demand. The applicant states that based on its analysis, it identified

open access, Hispanic and multicultural outreach and the under 65 age

cohort as special programs and populations in Broward County. The

applicant states its „open access‟ program will allow Broward County

residents to receive all effective medical options available for the relief of

pain and other symptoms, even if these are expensive or technologically

advanced. Hispanic and multicultural outreach is needed based on the

increasing Hispanic population and deaths, comparing the penetration

rate for service to Hispanics in Broward County to Florida and the lower

Hispanic admission rate to hospice from acute care hospitals. The

applicant also cites the low penetration rate for Broward County‟s under

age 65 hospice admissions compared to the state average. HPBC

indicates its service to these patients in Palm Beach County is support

for its contention that it will increase service to Broward County‟s under

age 65 population.

Demographic Trends

The population of District 10 is estimated to be 1,744,625 residents in

2010 and is projected to grow annually at 0.4 percent through 2015 to

1,790,310 residents, which is an incremental increase of 45,685

residents. The population of residents under 65 makes up a majority of

the population and it anticipated to grow 0.2 percent annually during the

five-year period from 1,488,223 persons in 2010 to 1,503,697 or by


29

15,474 persons in 2015. The applicant states that while not the primary

consumers of hospice care, the under 65 population is largely

underserved. Hospice of Palm Beach County states it already has

programs in place to address the needs of this population. The applicant

states that the 65 and over population is also growing more rapidly from

256,402 in 2010 to 286,613 in 2015 or by 30,211 persons at 1.9 percent

annually. The increase in both the under 65 and the 65 and over

population indicates that the number of patients requiring hospice

services will continue to expand over the next several years.

The applicant undertook an analysis of Broward County population

growth by zip code and found the most rapid growth in the zip codes

surrounding Coral Springs, West Pembroke Pines, and East Everglades.

The applicant states that the existing hospice providers do not have

offices in these areas and it will establish its presence throughout

Broward County over time and will ensure that the needs of higher

growth areas are met.

The applicant provides Broward County population projections from

2009 to 2014 based on Claritas data by race and notes that non-white

populations are growing at a faster rate than whites, although whites

comprise the substantial majority of the population9. This data indicates

an incremental growth of 106,856 residents from 1,755,970 in 2009 to

1,882,826 in 2014. Whites account for 1,144,236 of the 2014 projected

total population or 60.77 percent of the total population, but are only

3,774 or 3.53 percent of the 106,856 incremental increase. The largest

projected increase is the African-American population at 61,675 persons

or 57.71 percent of the total. Hospice of Palm Beach County asserts that

these growth patterns indicate that a new hospice provider in the area

must be prepared to develop programs that address increasing diversity.

Diversity programs, including racial, ethnic, and religious differences, are

of importance to Hospice of Palm Beach County.

The applicant states that the most notable growth is in the Hispanic

population. Broward County‟s total population increased from 1,718,179

to 1,869,880 or by 8.8 percent between 2000 and 2008. Hispanic

residents under age 65 are estimated to have increased by 57.5 percent

from 272,368 in 2000 to 429,103 in 2008, while Hispanic residents 65

and over are estimated to have increased 73.8 percent from 18,658 in

2000 to 32,428 in 2008. The applicant states that the size of the

Hispanic population is ample and makes up 25 percent

9 Projected Population for Broward County Population by Race and Annual Rate of Change, 2009-2014, Claritas,

Inc. 2008, Exhibit 15; CON Application #10085, page 71.


30

(461,531/1,869,880 is 24.68 percent) of the population10. The

applicant‟s data indicates that Broward County‟s non-Hispanic

population declined by 1.3 percent from 1,427,153 in 2000 to 1,408,349

in 2008 and the non-Hispanic age 65 and over population declined

nearly 10 percent in eight years from 242,451 in 2000 to 219,068 in

200811. The applicant concludes that this is evidence that a new

provider in the county needs to be able to address the needs of both the

under 65 and Hispanic populations and be prepared to offer bilingual

services and other culturally sensitive services to meet the needs of the

community.

Hospice of the Palm Coast next addresses mortality rates and patterns in

Broward County from 2003 through 2008. The applicant states that

total deaths are decreasing, but are increasing in the under 65

population segment. The applicant states that deaths in persons age 45

to 64 have increased from 2,471 in 2003 to 2,599 in 2008 or by 5.2

percent. However, deaths in the age 64 and under group age actually

decreased from 3,744 in 2003 to 3,736 in 2008 or by 0.2 percent. The

applicant contends that a new hospice provider must be prepared to

meet the needs of non-traditional hospice patients with an emphasis on

younger patients and patients with a variety of cultural and ethnic

backgrounds. The applicant concludes that the younger age group is

experiencing a much faster rise in number of deaths annually, which

points to the importance of serving this age group. Hospice of Palm

Beach County states that one important aspect of care to the under age

65 population is ensuring a broad range of treatment options since

patients in these cohorts are likely to be more hesitant about abandoning

curative services. The applicant asserts that it is uniquely positioned to

serve these younger patients because of its commitment to open access.

The applicant‟s data indicates that Hispanic under age 65 deaths

increased from 372 in 2003 to 481 in 2008 and Hispanics age 65 and

over deaths increased from 630 in 2003 to 922 in 2008. Hispanic deaths

increased by 40 percent from 1,002 in 2003 to 1,403 in 2008. Whereas

Broward County total deaths decreased from 15,604 in 2003 to 14,616

or by 6.3 percent. The applicant states people of Hispanic heritage

represent nearly 10 percent of the deaths and given the growing

significance of this ethnic group, a new hospice provider must be

prepared to meet the needs of this population.

10 Population of Broward County by Ethnicity in 2000 and 2008 population based on Florida Office of Economics

& Demographic Research per CON Application #10085, page 72. The applicant‟s numbers in Exhibit 16 compute

to 24.7 percent (461,531/1,869,880). 11 Ibid.


31

Regarding current HSA 10 hospice providers, the applicant states there

are no existing providers with offices located in the most rapidly growing

areas of Broward County: Coral Springs, west Pembroke Pines and east

Everglades. The applicant states that not only are these areas projected

to have the most population growth overall but the most Hispanic

population growth as well. The applicant states its proposed office

location will be poised to serve this growing demographic group.

Historical Utilization of Hospice Services in Florida and Broward County

In 2008, Hispanic residents comprised 24.7 percent (461,531/1,869,880)

of Broward County‟s population. The applicant states that although

Hispanics account for 12.3 percent (22,479/183,465) of all hospital

discharges in Broward County, they accounted for 6.7 percent

(298/4,445) of discharges to hospice12. The applicant states that

Hispanics under age 65 make up 14.7 percent of hospital discharges in

Broward County. The applicant provides percentages only here so it

appears that what is being stated is that Hispanics under age 65 make

up 14.7 percent of the total under age 65 hospital discharges in Broward

County. The applicant‟s Exhibit 22 (percentages only) table supports

this. However, discharges to hospice for under age 65 residents

represents 8.3 percent of total under age 65 discharges to hospice13. The

applicant‟s Exhibit 22 (percentages only) table supports this. Hospice of

Palm Beach County asserts this signifies a disparity in rate of use of

hospice services; while acute care discharges to hospice are just one

component of hospice admissions, it is reasonable to assume that overall

hospice admission demonstrate similar ethnic disparities. Thus, Hospice

of Palm Beach County states it will focus on serving the underserved

residents of HSA 10 to ensure Hispanic individuals of all ages receive

education on the availability of hospice services and the importance of

hospice care in the dying process.

In reference to increasing Hispanic access, Hospice of Palm Beach

County provided a table on page 21 of its application which indicates

that 312 of its 6,402 or 4.9 percent of its FY 08-09 admits were Hispanic

patients. Hispanics were 5.7 percent (753/13,160) of Palm Beach

County‟s 13,160 deaths in CY 08. The applicant indicates this

demonstrates its contention that its programs/service will increase

Hispanic access in Broward County.

12 Comparison of Inpatient Discharges, Discharges to Hospice, and Population, Exhibit 21; CON Application #10085, page 77. 13 Proportion of Discharges to Hospice by Ethnicity, Exhibit 22; CON Application #10085, page 78.


32

Hospice of Palm Beach County states it will increase utilization of

hospice services among this population by addressing the unique

language and cultural needs of the Hispanic population. The applicant

intends to expand its existing Palm Beach programs to Broward County.

Hospice of Palm Beach County states that if there were no cultural,

financial, or socioeconomic barriers to care, it would stand to reason that

Hispanic patients would be accessing hospice services at a rate similar to

their percentage of the overall population. Such utilization trends

suggest that the cultural, religious, and philosophical differences that are

prevalent in this group may impact the rate of hospice use. The

applicant states that special community efforts, clinical protocols, and

bereavement services for families will be implemented to increase

participation in hospice for groups traditionally underrepresented.

Potential to Increase Hospice Penetration Rates

The applicant states that it is important to note that District 10 ranks

22nd of the 27 subdistricts in Florida in hospice penetration. The

applicant states the penetration rate in District 10 dropped between

2007 and 2008 from 57.31 percent to 55.75 percent14. For the applicant

this demonstrates there is potential to increase hospice penetration rates

in District 10, through greater patient education, outreach to referral

sources, and the availability of greater range of options such as those

provided through its open access policy.

Hospice of Palm Beach County states it has demonstrated its ability to

grow hospice penetration rates in HSA 9C. The applicant states that the

HSA 9C hospice penetration rate increased from 66.83 percent (8,792

admissions/13,156 deaths) in 2006 to 69.98 percent (9,209

admissions/13,160 deaths) in 2008 and this increase was due to its

efforts to grow hospice admissions15. HPBC admissions increased from

6,013 in 2006 to 6,403 in 2008 or by 6.5 percent.16 The applicant notes

that there were no new hospice programs in the district during the time

period. Hospice of Palm Beach County states it would bring an effective

alternative to Broward because it is a mission driven organization that

goes above and beyond when caring for patients and is not focused on

return on equity for shareholders like many for-profit corporations.

14 Comparison of Hospice Penetration Rates, Exhibits 23 - 25; CON Application #10085, pages 80-82. 15 Historical Admits by Provider in Palm Beach County, Exhibit 26; CON Application #10085, page 83. 16 Agency data for the appropriate periods confirm HSA 9C‟s and the applicant‟s admissions and reported deaths (CY 2008 deaths based on Florida Vital Statistics Annual Report for CY 2008).


33

The applicant states it expects to not only serve the projected growth in

hospice utilization based on the Agency need methodology, but also to

increase the penetration rates by targeting historically underserved

populations. Hospice of Palm Beach County states it serves all age

categories and is well suited to serve the under age 65 population

because of its open access policy that encourages younger patients facing

serious illness to view hospice services as an appropriate alternative.

Projected Utilization of Proposed Program

The applicant states that projected market shares were applied to

projected total hospice admissions to calculate the number of admissions

by category and age that it would serve. Rates are generally based on the

experience of other hospices in Florida. The applicant states that its

market shares are expected to be 2.9 percent in year one and 6.5 in year

two. The applicant states that the assumed average lengths of stay were

multiplied by the projected admissions to determine the projected patient

days. The average length of stay are expected to be 60 days in year one

and two respectively17. Hospice of Palm Beach County anticipates it will

serve 250 hospice patients in year one and 570 hospice patients in its

second year of operation. At this level of utilization, the applicant states

it can operate a hospice that will offer high quality care, have a sufficient

base of patients to be financially viable, and provide a foundation for the

development of the comprehensive programs and services. Hospice of

Palm Beach County anticipates meeting its projections without

significant impact on the existing providers in the district.


HealthCare of Central Florida, (CON #10086) provided a profile of

HSA 10 including demographic data, major causes of death and chronic

disease, the limitations of the current hospice system, and the existence

of special and not normal circumstances within the service area that

demonstrate need for its proposed program. The applicant also

discussed the rationale behind its project including enhanced access to

hospice services to terminally ill patients not being served and enhanced

patient access to unique clinical and support programs it offers. In

addition, the applicant provided an assessment of patient day forecasts

and its impact on the existing HSA 10 hospice providers.

17 Projected Utilization for Hospice of Palm Beach County in District 10, Exhibits 28 and 29; CON Application #10085, pages 86-87.


34

The applicant indicates that the Agency‟s September 2008 population

estimates show the July 1, 2010 total population of HSA 10 is 1,744,625,

which is projected to grow to 1,747,385 by 2012; an increase of 2,760

persons or 0.2 percent18. The applicant states that while growth in the

total population is important, a more important consideration is the

projected population of the older age cohorts of the service area

population. The applicant states that the 65 and older age cohort will

experience a greater percent increase in population than the younger age

cohorts. Fifteen percent (256,402/1,744,625) of the district‟s population

is over the age of 65 years and that population will increase by 9,447

persons to 265,849 or by 3.7 percent between 2010 and 2012. In

contrast, the Broward County population under age 65 will decrease

from 1,488,223 to 1,481,536 by 6,687 persons between 2010 and 2012.

These projections are based on the September 2009 population

estimates, and while not technically correct by rule, are much lower than

the September 2008 projections which indicate continued population

growth in all age cohorts. The applicant concludes that HSA 10 is home

to a large and growing population of those persons most likely to utilize

hospice services19.

The applicant states that while just under one-half of Broward County‟s

population is white, non-Hispanic, the Broward County Urban Planning

and Redevelopment Department, Planning Services Division has

presented reports on the growing Brazilian, Haitian/Creole-speaking,

Hispanic and African-American populations of Broward County20.

Odyssey indicates that it included publications regarding the growing

Brazilian, Haitian/Creole speaking, African-American and Hispanic

populations in the application‟s Appendix N. These “Broward-by-the-

Numbers” pamphlets were in Appendix P and the populations discussed

and dates published were: Brazilian in April 2006, Haitian/Creole-

speaking in December 2002 and African-American in November 2004.

All of these populations have experienced growth within Broward and

according to the applicant are expected to show continued growth in the

future. The applicant states that the Brazilian population has grown

from 1,713 in 1990 to 22,087 in 2004 with a majority of the population

concentrated in the northeast section of Broward County along the I-95

corridor near the cities of Coconut Creek, Deerfield Beach and Pompano

Beach. Similarly, the Haitian population, which has increased from

1,849 residents in 1980 to 47,445 Broward County residents who were

18 The applicant‟s population projections are actually from the Agency‟s September 2009 population estimates which were not approved in rule for use during this batching cycle. 19 District 10 Projected Population Growth, by Age Cohort 2010-2012, Table 4; CON Application #10086, page 57. 20 The Broward County Urban Planning and Redevelopment Department, Planning Services Division Publications; Appendix P; CON Application #10086.


35

born in Haiti in 2000, is also concentrated in the north eastern portions

of Broward County along portions of the I-95 corridor stretching from

Deerfield Beach and Pompano Beach southward to Fort Lauderdale. The

pertinent “Broward-by-the-Numbers” pamphlet indicates that Broward

County had 62,342 residents of Haitian ancestry in 2000. Haitian

ancestry residents were 3.8 percent of Broward total population. The

applicant intends to have its proposed second office in this area along

the I-95 corridor in central/northeast Broward County.

The Hispanic population has increased from just over 15,000 in 1970 to

over 271,000 in 2000. The majority of the Hispanic population lives in

west and southwest portions of Broward County (Miramar, Pembroke

Pines, and Weston) in an area of Odyssey‟s proposed southwest Broward

County office location. The applicant indicates this office will be located

along the I-75 corridor in southwest Broward County. According to the

applicant, data from the 2000 Census state that Broward County was

home to more than 300,000 African-American residents, making them

the County‟s largest minority population representing 20 percent of the

Broward County population.

The applicant asserts that the significance of this minority population

growth within Broward County is due to the fact that non-white

populations access hospice services at a far lesser degree than the white

population. The applicant states that data published in 2009 by the

National Hospice and Palliative Care Organization, 2008 data indicate

that 81.9 percent of all hospice patients were white/Caucasian; slightly

up from 81.3 percent in 2007. In contrast the percentage of hospice

patients that were black/African American decreased from nine percent

in 2007 to 7.2 percent in 200821. Multi-racial or other race patients

increased from 7.8 percent in 2007 to 9.5 percent in 2008. The

applicant states that Broward County is home to a large and growing

number of non-white residents who utilize hospice services to a lesser

extent than the white population and present a great opportunity to

improve existing hospice utilization rates in Broward County.

The applicant states that the total number of deaths in HSA 10

decreased from 2004 to 2007. With 15,376 deaths in 2004, HSA 10

realized a 5.2 percent decrease in deaths from 2004 to 2007 (14,578) and

then a slight upturn in deaths to 14,629 deaths in 2008 or an increase of

1.3 percent. While the applicant‟s narrative indicates the 2007 to 2008

increase is 1.3 percent it actually computes to 0.3 percent. Although the

number of deaths for total population decreased between 2004 and 2008,

21 NHPCO Facts and Figures: Hospice Care in America, 2009 edition; Appendix Q; CON Application #10086).


36

the number of deaths has increased for the white-Hispanic, black-non-

Hispanic, black-Hispanic and black-non-Hispanic-Haitian populations.

The applicant‟s table below documents the above assertion.

Broward County Deaths by Race & Ethnicity

CY 2004 - CY 2008

2004

2008 Absolute change

Percent change

Total All Races, All Ethnicities 15,326 14,629 -697 -4.5%

White, Non-Hispanic 12,164 10,924 -1240 -10.2%

White, Hispanic 961 1,334 373 38.8%

Black, Non-Hispanic 2,019 2,041 22 1.1%

Black, Hispanic 34 48 14 41.2%

Black, Non-Hispanic, Haitian 241 308 67 27.8% Source: CON Application #10086, page 67 from Florida Dept. of Vital Statistics. Note: The applicant’s five category breakdown exceeds the total deaths which compute to 15,419 in CY 2004 and 14,655 in CY 2008, so there is an apparent double counting or mathematical error.

The Florida Vital Statistics Annual Report of 2008 indicates that 12,268

of Broward County deaths were white and 2,358 were non-white

compared to Odyssey‟s total of 12,258 white and 2,397 non-white

deaths. Odyssey states that while some of the numbers are relatively

small (non-whites account for 16 percent of total 2008 deaths), the

implication of these racial/ethnic death trends is that while the largest

segment of the population in need of hospice care is the white-non-

Hispanic population, it is the Hispanic, African American/black and

Haitian populations in particular who are growing and will need

expanded hospice care into the future to meet the community‟s needs.

The applicant states that it is adept at implementing culturally diverse

programming and when entering a community, it hires nurses, home

health aides, physicians, physician directors, etc. from within the

community that is reflective of the local cultural, racial and ethnic

diversity of the community.

Odyssey states that when evaluating major causes of death in HSA 10,

heart disease accounted for the largest number of deaths (3,858/14,629)

at 26.4 percent, closely followed by cancer (3,354) accounting for 22.9

percent of deaths. Just as the trend in the number of deaths is different

between specific races and ethnicities in Broward County, the number of

deaths by specific causes of death also differs by race and ethnicity.

Odyssey states that in total and for the white population, heart disease

accounts for the greatest number of deaths; for African American/black

and other non-white populations death from heart disease were second

after cancer; cerebrovascular disease was the third highest cause of

death for all races. Chronic lower respiratory disease accounted for five

percent of deaths in the white population, but two percent in the African


37

American/black population22. Odyssey states it is its intent to offer

disease specific hospice programs to support unique race-specific

mortality indicators such as cerebrovascular disease, diabetes, and HIV.

Odyssey states it has the ability and experience base to treat all patients

in need of hospice care including Haitian, Brazilian, Hispanic and African

American populations, and is prepared to do so in HSA 10. Odyssey

states its CareBeyond programs are a series of disease-specific programs

that insure that hospice patients receive the highest quality care

possible.

For the most recent 12 months of data, the applicant states, HSA 10 had

the 5th lowest utilization rate of all 27 hospice service areas for total

hospice utilization. HSA 10 had 56.67 percent (8,260 CY 2009 hospice

admissions divided by 14,576 CY 2007 deaths) of its dying residents

served by a hospice agency. The statewide average was 63.81 percent

based on the state‟s 106,898 CY 2009 hospice admissions divided by

167,530 deaths in CY 2007. The applicant states that HSA 10 has been

consistently underserved by the existing providers when compared to

statewide average over the last seven batching cycles23.

Odyssey states that there is a large and growing pool of both cancer and

non-cancer patients that will ultimately be requiring hospice care and

with the current HSA 10 hospice utilization rates below the statewide

rate for hospice patients in total and for each of the four patient groups

(cancer patients under the age of 65 years, cancer patients over the age

of 65 years, non-cancer patients under the age of 65 years and non-

cancer patients over the age of 65 years), it is clear that both a cancer

and non-cancer focus is critical in providing optimal hospice services in

the HSA 10 market.

Patients Served By Patient Category

Hospice Service Area 10, April 2010 Batching Cycle Cancer

<65 Cancer

>65 Non-Cancer

<65 Non-Cancer

>65

Total

Hospice Admissions 669 2,010 453 5,128 8,260

Resident Deaths 933 2,445 2,830 8,368 14,576

% of Deaths Served 71.7% 82.2% 16.0% 61.3% 56.7% Source: Table 25, CON Application #10086, page 92.

22 Major Causes in Death by Race, 2004 and 2008, Tables 12, 13 and 14; CON Application #10086, pages 69 and 70. 23 Total Hospice Utilization by Batching Cycle April 2007 through April 2010 Hospice Service Area 10 and Florida, Table 21; CON Application #10086, page 85.


38

As shown above the utilization levels range from a high of 82.2 percent

for cancer patients over 65 to a low of 16.0 percent for the non-cancer

patients under 65. According to the applicant, the discrepancies

between the resident deaths and hospice admissions in HSA 10

represent a population of residents who could have potentially benefitted

from hospice and did not receive those services.

Odyssey states that its proposed program will be able to bring its breadth

of hospice experience and expertise to the market and quickly identify

the existing system limitations that have resulted in these consistently

underserved populations. Once these limitations are identified, Odyssey

states it will bring required programs and services to the local area to

enhance existing programs and services and to ensure that all HSA 10

residents, regardless of race or ethnicity, access beneficial hospice care

to at least the same extent as they are accessed statewide.

Odyssey intends to establish two office locations in Broward County to

provide access to major thoroughfares as well as to provide easy access

for the growing racial/ethnic populations within Broward: African

American/black, Hispanic, Brazilian and Haitian populations. The first

proposed location is in the southwest sector of Broward County along the

intersection of I-75 corridor. The second location will be located along

the I-95 corridor in central/northeastern Broward County. The applicant

states that these proposed locations will provide care to the major

population hubs within the service area and will also provide distributed

access to the underserved populations.

Odyssey concludes its analysis with a forecast of its anticipated patients

from the service area. The applicant states that based on its startup

experience and the HSA 10 market size it anticipates patient admissions

at the end of the first year of operation to be 224, with an average daily

census (ADC) of 43.5. Year two hospice admissions are forecasted to be

410 admissions with an ADC of 87 at the end of the second year of

operation. Odyssey states that reviewed on a patient day basis, this is a

forecast of 8,636 hospice days of care for year one growing to 24,566

days of care for year two and an expected length of stay of 38 days in

year one and 60 days for year two when forecasted admissions and days

are compared. Odyssey states that year one requires 2.2 to 2.6 percent

market share, while year two target admission volumes will require 4.0 to

4.6 percent market share capture to reach forecasts.


39

2. Agency Rule Criteria and Preferences a. Rule 59C-1.0355(4)(e) Preferences for a New Hospice Program. The

agency shall give preference to an applicant meeting one or more of the criteria specified in the below listed subparagraphs:

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

commitment to serve populations with unmet needs.

Each applicant is responding to published need for an additional

hospice program for the July 2011 planning horizon.

Each applicant discusses serving populations they believe to be

underserved.

Compassionate Care Hospice of Florida, Inc. (CON #10083)

commits to meeting the needs of all patients and their families in

need of end-of-life care in Hospice Service Area 10. Compassionate

Care states that it will serve all patient populations within the four

age/diagnosis cohorts as well as specific underserved populations

which include terminally ill residents of Hispanic decent and

residents of Jewish faith.

Douglas Gardens of Broward, Inc. (CON #10084) identifies

residents of assisted living facilities and nursing homes as

underserved populations and commits to serving them with

specific programs. The applicant states that the provision of

services to nursing home residents is lower in Broward County

than in the rest of the state. According to the applicant, Broward

County had a total of 707,783 hospice patient days of which

123,586 or 17.46 percent were provided to nursing home patients

and the state 8,521,162 hospice patient days with 2,030,343 or

23.83 percent provided to nursing home patients. The applicant

states that its hospice in District 11 had 21,662 total patient days

in calendar year 2009, of which 7,324 or 33.81 percent were in

nursing homes24. Thus the applicant states it has nearly twice the

penetration rate of service to residents in nursing homes than is

provided in HSA 10.

24 CON Application #10084, page 2-5, Table 2-1: Hospice Days of Care Delivered to Residents of Nursing Homes with Percent of Total Reported Patient Days, CY 2009.


40

Hospice of Palm Beach County, Inc. (CON #10085) states that

HSA 10 is underserved with particular need demonstrated for

Hispanics, persons under the age of 65 and those who desire

complex palliative interventions. Hospice of Palm Beach County

states that demographic trends, including population growth rates

and increasing number of deaths, also support the need for greater

services to the Hispanic population. In order to meet this need the

applicant commits to address the specific needs of patients who

are Hispanic and includes information in clinical training

programs to meet this community need. Hospice of Palm Beach

County ensures that the community will be made aware of their

special programs for Hispanic patients through their community

outreach and educational efforts. The applicant states it will also

meet the needs of the underserved in the hospice service area by

establishing an office in the Coral Springs area the first year and

adding a second office in the southwestern region by the first

quarter of the second year. Hospice of Palm Beach County states

it will pay attention to systematic outreach, education, support

groups and recruitment of volunteers and staff in the Hispanic

community. The applicant‟s teen volunteer program will recruit

Hispanic teens to assist with this effort. Marketing materials,

relevant forms and program information in Spanish will be utilized

and prepared specifically for the services in HSA 10.


HealthCare of Central Florida (CON #10086) commits to serve

populations with unmet needs and will address the special and not

normal circumstances that exist within HSA 10. The applicant

states the residents of HSA 10 have been consistently underserved

by the existing hospice providers as evidenced by the current total

hospice utilization rate that is the 5th lowest utilization rate of all

27 hospice service areas. The applicant also identified the

following as consistently underserved patient groups: cancer

patients under the age of 65 years, cancer patients aged 65 years

and older, and non-cancer patients under the age of 65 years, non-

cancer patients aged 65 years and older, and Broward‟s minority

population residents.


41

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

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

Compassionate Care Hospice of Florida, Inc. (CON # 10083)

intends to have contractual agreements with nursing homes and

hospitals, as well as other healthcare providers designed to meet

patient needs in Broward County. Compassionate Care states by

partnering with hospitals and nursing homes to provide hospice

inpatient care; it will fulfill its goal to expand awareness and

utilization of hospice. The applicant states it operates four

dedicated inpatient units in its Delaware and New Jersey

programs. The applicant provides letters of support from

Plantation General Hospital, Kindred Hospitals South Florida,

Southern SNF, Park Summit (continuing care retirement

community), and The Forum at Deer Creek all stating their

willingness to enter into agreements with Compassionate Care to

provide inpatient care. Compassionate Care Hospice anticipates

that it will negotiate contractual arrangements with hospitals and

nursing homes in all geographic areas of the service area.

Douglas Gardens of Broward, Inc. (CON #10084) proposes to

provide the inpatient care component through contractual

agreements with area hospitals and nursing homes. The applicant

provided a letter from Pompano Rehabilitation and Nursing Center

stating its willingness to enter into a contractual agreement for

inpatient beds. Douglas Gardens will seek additional agreements

from area hospital and nursing facilities.

Hospice of Palm Beach County, Inc. (CON #10085) proposes to

provide the inpatient care component of its new hospice program

through contractual agreements with existing health care facilities,

including the acute care hospitals in the district, and skilled

nursing facilities. The applicant has letters indicating a

willingness to contract for inpatient services from Northwest

Medical Center, Life Care Center at Inverrary, West Broward

Nursing and Rehab Center, Seaview Nursing and Rehabilitation

Center, Broward Nursing and Rehabilitation Center, The Health

Center of Coconut Creek, Harbor Beach Nursing and

Rehabilitation Center, Hillcrest Nursing and Rehabilitation Center,


42

and Fort Lauderdale Health and Rehabilitation Center. Hospice of

Palm Beach County states negotiations for additional contracts

with hospitals and additional nursing homes will be ongoing to

ensure the widest network.


HealthCare of Central Florida (CON #10086) will use existing

licensed hospital and skilled nursing facility beds to serve patients

in need of inpatient hospice services. Odyssey states it has been

able to establish arrangements with providers in service areas

where their hospices already exist and foresees having the same

success in HSA 10. Odyssey provides letters of support indicating

a willingness to negotiate for general inpatient hospice care from

the following facilities: Westside Regional Medical Center,

Plantation General Hospital, Kindred Hospital South Florida-Fort

Lauderdale, Kindred Hospital South Florida-Hollywood, and South

Florida State Hospital. The applicant is involved in ongoing

discussions with other potential provider partners in HSA 10.

(3) Preference shall be given to an applicant who has a commitment to serve patients who do not have primary caregivers at home; the homeless; and patients with AIDS.


commits to serving all patients including those who do not have

primary caregivers at home, the homeless, and patients with AIDS.

The applicant states that this commitment is evidenced by the

existing admissions policy and by the Compassionate Care related

entities history of provision of care to these populations.

Compassionate Care Hospice states it delivers almost 12 percent

(11.8 percent) of its care to patients who either live alone or with a

compromised caregiver, including nearly nine percent (8.5 percent)

to those living alone.

The applicant states that it is committed to serving those with

AIDS in addition to its commitment to serving patients either

without caregivers at home or with compromised caregivers and

homeless individuals. The applicant states that typically, if a

patient is in need of hospice care and is homeless, it will place the

patient in an inpatient unit and assist in applying for Medicaid;

once the patient qualifies, he/she is placed in a long-term care

environment where the patients can begin or continue hospice

care.


43

However, the process of qualifying the homeless for Medicaid can

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

is by qualifying for Supplemental Security Income (SSI) benefits

through social security. Once becoming eligible for SSI, Medicaid

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

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

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

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

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

private shelter.

Douglas Gardens of Broward, Inc. (CON # 10084) expects that

some persons will not have a designated person who can function

as a primary caregiver; the hospice team leader will identify and

direct safe and effective provision of hospice care in situations

where the terminally ill patient requires assistance with self-care

and skilled services. According to the applicant, care will be

provided in a location in accordance with the patient‟s wishes.

The applicant states that if the patient is initially unable to meet

their own needs for self care and symptom management, the

interdisciplinary team will identify “lack of primary caregiver” as a

problem. Possible interventions would include: a social worker

assessment of the patient‟s ability and desire to pay independently

for hired care givers; a discussion of anticipated care needs with

the patient and collaboration on a plan to meet those future needs.

The applicant states that as decline in functional ability develops

with progressive disease, the type of assistance needed will be

determined by the interdisciplinary team in collaboration with the

patient and family (if involved) and the following potential solutions

will be explored: friends, neighbors, and community members as a

potential support network; the hospice team will provide support,

management, teaching, oversight, and emergency intervention to

this network if one is identified; placement in group home, public

housing, or shelter; placement in a skilled nursing facility;

continuous care plan if pain and symptoms are unmanageable by

arranged caregiver support and the patient desires to remain at

home; or placement in a general inpatient bed when pain and

symptoms are unmanageable at home.

The homeless, according to Douglas Gardens fall into the same

category as persons without a primary caregiver and the same

protocols would be used.


44

The applicant states that through its owners it brings expertise in

the provision of care to persons with AIDS.

Hospice of Palm Beach County, Inc. (CON #10085) states that it

provides service to everyone who makes an inquiry, beginning with

information, education, referral, and counseling and admits all

patients who qualify for hospice care within our licensed service

area, including homeless persons, persons without primary

caregivers, and persons with HIV or AIDS.

The applicant states that it recognizes that patients and families

coping with a life-threatening illness often face unexpected

financial challenges. The Hospice of Palm Beach County

Foundation has established the Helping Hands Program to help

families with concrete needs like rent, utility and telephone bills,

food, or funeral expenses. The applicant states that Helping

Hands also provides grants for paid care giving in the home, which

can extend a family caregiver‟s ability to continue working, or

provide extended assistance with the increasing burdens of care

giving as the patient declines. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida (CON #10086) states that they

provide services to all patients who meet the criteria for admission

to hospice, including patients who do not have a primary caregiver

at home, the homeless, and patients with AIDS. Odyssey‟s non-

discrimination policy states:

Odyssey offers palliative care to terminally ill patients and support to

those patients and their families without regard for diagnosis,

gender, sexual orientation, national origin, race, creed, disability,

age, place of residence or ability to pay.

In the event a patient is impaired with physical problems that can

no longer be managed at home, or if a patient is homeless, Odyssey

states its nurses will evaluate the patient for possible inpatient

admission to a hospital or long-term care facility. Odyssey states

that its nurse will coordinate the admission with the attending

physician or hospice physician and the interdisciplinary team.


45

Odyssey states its teaching materials for HIV teaches referral

sources how to identify patients who may be eligible for hospice

service, to provide aggressive pain and symptom management,

psychosocial, spiritual and emotional support for patient and loved

ones, and teaching what to expect as the illness progresses.

Odyssey expresses it is fully prepared to admit patients with

HIV/AIDS.

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

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

Hospice Service Area 10 consists of one county, Broward. This

criterion is not applicable to this review.

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


states it offers a host of special programs and services that are not

specifically covered by private insurance, Medicaid or Medicare.

The applicant commits to provide the following non-core services:

Pathways to Compassion - a palliative care program whose

mission is to prevent and relieve suffering and to support the

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

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

hospice patients in either state or federal reports. Palliative

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

debilitating condition.

Complementary Care Program - services offered in this program

are massage therapy, music therapy, energetic care, sacred

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

Transitions - a community service program, designed to

enhance the quality of life for individuals and their families

facing life-limiting illnesses. Services include emotional

support, education, and practical assistance such as running

errands, performing house chores and food preparation.

Transitions is a free service provided to eligible residents/

patients and is funded by Compassionate Care Hospice and

community donations.


46

Jewish Hospice Program – Compassionate Care Hospice

provides and coordinates resources and services that meet the

needs of the Jewish Community surrounding loss, life‟s

changes, terminal illness, dying and grief.

Hispanic Hospice Program – Compassionate Care Hospice

develops all Hispanic/Spanish speaking interdisciplinary teams

to serve the needs of these patients. All patient informational

brochures are available in Spanish and all team members are

bilingual, including chaplains, nurses, social workers and

others. Staff is trained on cultural sensitivities and recognizes

important Hispanic related dates and events.

Compassionate Care 4 Kids – services are provided in a team

approach to patient care strengthened for Compassionate Care

Hospice partnerships with local children‟s hospitals.

Life Enhancement Specialists – are paid employees at

Compassionate Care Hospice who provide recreational activities

for socially isolated patients. The life enhancement specialist

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

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

music, conversing with the patient and keeping this person

company. Schedule 6 provides for one FTE life enhancement

specialist.

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

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

family to maintain the home. Homemakers are not licensed

professionals and therefore they cannot do all activities of daily

living such as bathing the patient. Schedule 6 provides for one

homemaker FTE.

Cardiac Connections - is a care model developed to meet the

unique needs of patients with advanced cardiac disease and

congestive heart failure. Treatment will greatly reduce or

eliminate visits to the emergency room and hospitalization.

Promise Program – meets the requirements of needy

populations. Compassionate Care Hospice provides a

supportive network of medical, nursing, and psychosocial

interventions for patients who may be considering stopping

dialysis treatments.


47

First Night at Home – program is designed to ensure new

hospice patients receive a little extra support the first few days

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

shifts. Weekend personal care support is readily available to all

patients.

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

needs of this patient population by assisting veterans in

accessing available services and supports offered to veterans.

Community Outreach – reaches out to local schools and

supports children experiencing the death of a loved one.

Compassionate Care Hospice teams will participate and sponsor

community toy and food drives around the holidays.

Compassionate Care Hospice will also partner with local

hospitals and healthcare organizations to reach beyond hospice

and focus on wellness and patient education; and attend

and/or host community health and wellness fairs and other

events.

Volunteer Services – trained volunteers will be used to provide

administrative support and direct patient care. Volunteer

services will be based on patient need and requests as assessed

by the volunteer coordinator.

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

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

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

memorial services in long-term care facilities and assisted living

facilities.

Rainbows – is a bereavement support program for children who

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

Comfort Corners – is a program in which Compassionate Care

Hospice sponsors designated areas within a long-term care

facility and decorates the area to resemble a warm, home-like

environment for hospice patients and their families.


48

Douglas Gardens of Broward, Inc. (CON # 10084) will provide the

following programs that are beyond the core hospice services

provided by insurance, Medicare, and Medicaid:

Music therapy – techniques used include: gentle touch and/or

massage with music; guided imagery; singing/instrumental

work; lyric analysis/discussion; song writing; music relaxation;

recording personal tape; drum work; breath work; making

music choices and listening; rhythmic movement and dance.

Pet therapy – scheduled pet visits by therapy dogs and handlers

are noted in plan of care.

Palliative Care Program – provides clinical symptom

management for people living with an advanced illness and

emotional support for their families and caregivers.

Touch for all Seasons – a comprehensive program for patients

with Alzheimer‟s disease and other types of dementia.

Open Access – covers services many other hospices won‟t

consider like ventilators at home, radiation therapy, and

chemotherapy.

Pharmacy Consult – available 24/7 for all of nurses and

physicians to assist in pharmacological consultation.

Education – internal education is of the highest caliber available

external/community education by the top speakers to ensure

that nursing personnel and other professionals can earn

required CEU for maintaining licensure and certification

requirements.

Kangaroo Kids Sumer Support Camp – for bereaved children

that includes a weekend trip with parent/guardian to one of

Florida‟s theme park.

Kangaroo Kids – consists of child and family-focused

professionals committed to supporting families who care for

their children at home. The close knit team is assigned to the

family and child and remains with them throughout the end-of-

life process.


49

Volunteer Vigil Program – vigil volunteers are direct patient care

volunteers who have completed all core volunteer requirements,

six months active patient care and expressed an interest in vigil

by signing a participation request.

Call Center – for afterhours triage of calls with Douglas Gardens

employees who are specifically trained in hospice and palliative

care and have access to all patients‟ up to date patient

information.

Hospice of Palm Beach County, Inc. (CON # 10085) states it

currently provides a broad range of services that are not covered by

private insurance, Medicaid, or Medicare. Specific non-covered

services provided include:

Complex palliative care, including chemotherapy, radiation,

blood transfusions and other disease altering but non-curative

interventions that improve quality of life and comfort

Extubation or Ventilator Withdrawal Program – as an element of

the open access, Hospice of Palm Beach County has developed

methods of assisting families and patients facing the difficult

question of withdrawing mechanical breathing

Bereavement and Grief Support Programs that are available to

all service area residents: individual and family grief support;

anticipatory grief support for children and teens; camp sea star

children‟s camp; teen bereavement program; telephone grief

support; grief support groups; school support groups; coping

with holidays program; nature of grief education/support

programs; specialized support for pregnancy and infant loss

(SHARE); annual celebration of life service; annual candlelight

ceremony for SHARE program

Integrative and Expressive Therapies – music, art, massage, pet,

reiki, and aromatherapy

Supportive counseling or consultation with patients or families

addressing issues of serious illness, even if they do not qualify

for hospice benefit

Helping hands covers non-healthcare related services, such as

in–home custodial care, as well as minor purchases to foster

quality of life and maintain at home, such as telephone or

wheelchair ramp


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Music therapy intern program

Volunteers to provide respite for caregivers at home, assistance

with errands and light homemaking tasks

Services to persons who have exhausted their insurance benefit

Recruitment, training and use of volunteers to augment Hospice

of Palm Beach County‟s capabilities including professional

volunteers who are massage therapists, licensed counselors,

lawyers and pharmacists

Services to veterans

Veteran recognition events

Services to citizens of other countries residing in the service

area, even if they have no hospice coverage

Community Education: lunch and learn; caregiver education;

and heart to heart introduction of the hospice team to local

community groups

Employee Programs: employee health nurse, employee wellness

program; free yoga and meditation and low-cost aerobics

classes; education on exercise and nutrition; monthly drop-in

staff group offered by local psychologist; onsite gym; finance

and money management

Hospice of Palm Beach County states it conducts all of its activities

according to its “Open Access” approach which goes beyond simply

admitting all patients who qualify for hospice care; this process

means that Hospice of Palm Beach County actively seeks to reduce

and remove barriers to care wherever they may arise for a

prospective patient, whether the barriers are internal or external.


HealthCare of Central Florida (CON #10086) states it will provide

services that are not specifically covered by private insurance,

Medicaid or Medicare. These services include: pet, music,

massage, laugh and aroma therapies, dialysis, palliative radiation,

and palliative chemotherapy treatments. The applicant states that

it has the ability to identify and respond to the unique needs of the

communities it serves. Odyssey Miami-Dade/Monroe program


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provides the Memory Bear program, massage therapy, hospice

education for Hispanic community and its chaplain provides

funeral services free of charge for requesting families. The Odyssey

Volusia-Flagler program provides services to ventilator patients

(some of whom are not admitted to hospice Odyssey provides care

to the patients and bereavement services for their families),

provides care to patients on feeding tube, and provides music

therapy and music therapy CDs and pet therapy services. Odyssey

states that the following services (included in its conditions of

participation) will reinforce its willingness to provide the required

services as well as its willingness to go beyond what is required in

order to serve their patients.

The applicant will provided hospice services 24 hours a day,

seven days a week including care as indicated by the patient‟s

medical condition.

The applicant commits to having every patient assessed by the

interdisciplinary team upon admission to the hospice.

The applicant will provide routine care which includes: daily

contact, CareBeyond program, and the tuck-in process.

The applicant will provide education services to include:

community education representatives, community liaisons, and

clinical liaisons.

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

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

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

(a) Proposed staffing, including use of volunteers.

Compassionate Care Hospice of Florida, Inc. (CON

#10083): As reflected in Schedule 6A of the application, the

following is the proposed staffing for each of the first two

years of operation.


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Position Average Number of FTE Year One

Average Number of FTE Year Two

Administrator 1.00 1.00

Professional Relations Coordinator 1.50 1.50

Secretary 1.00 1.00

Community Liaison 1.00 1.00

Medical Director 0.10 0.45

Registered Nurse 1.00 7.00

Per Diem Registered Nurses 0.80 2.00

Licensed Nurse Practitioners 1.00 2.00

Per Diem Lic‟d Nurse Practitioners 0.00 0.80

Nurses Aides 3.00 14.00

Per Diem Nurses Aides 1.00 1.80

Homemaker 1.00 1.00

Life Enhancement Specialist 1.00 1.00

Continuous Care Per Diem LPN 0.09 0.42

Continuous Care Per Diem Aide 0.09 0.42

Music Therapist 0.20 0.20

Massage Therapist 0.20 0.20

Dietary Services 0.20 0.20

Social Worker 1.00 2.00

Volunteer Coordinator 1.00 1.00

Chaplain 0.50 1.00

Total 16.68 39.99 Source: CON Application #10083, pages 94-95 & Section 3 Schedule 6A.

Douglas Gardens of Broward, Inc. (CON #10084): As

reflected in Schedule 6A of the application, the following is

the proposed staffing for each of the first two years of

operation.




Admissions 1.00 1.00

Team Coordinator 1.00 1.00

Team Assistant 1.00 1.92

Business Development 1.00 1.00

Human Resources 1.00 1.00

CC Coordinator 1.00 1.00

Clinical Administrator 1.00 1.00

RNs/LPNs 13.08 19.17

Nurses Aides/HHAs 4.50 6.75

Dietician 0.75 1.00

Chaplain 1.00 1.67



Music 1.00 1.00

Total 31.16 41.51 Source: CON Application #10084, Exhibit 5-2, Schedule 6A, pages 14-15.


53

It is noted that the applicant does not list FTEs for a medical

director or ancillary services. However, the applicant states

that a part-time medical director will be contracted and that

contract arrangements are expected to be utilized for

rehabilitative/palliative therapy services.

Hospice of Palm Beach County, Inc. (CON #10085): As



operation. It is noted according to the applicant Schedule

6A represents only hired staff therefore volunteers are not

listed. However, Hospice of Palm Beach County anticipates

it will recruit, train, and use volunteer staff at approximately

the same proportion of overall staff as that currently found

in its Palm Beach hospice.




Medical Records Clerk 0.50 1.00

Associate Medical Directors 0.50 1.00

RNs 4.00 9.00

Hospice Aides 4.00 9.00

ON-Call Nurse 2.00 3.00

Continuous Care 1.00 4.00

Manager 0.00 1.00

Integrative Therapist 0.50 1.00


Social Workers 2.00 3.00

Bereavement Counselors 0.50 1.00

Chaplain 1.00 1.50

Secretary 0.00 2.00

Courier 1.00 2.00



Total 27.50 54.50 Source: CON Application #10085, Schedule 6A, pages 155-156.

The applicant does not provide FTE designation for a

registered dietician, instead the applicant lists 7.10 FTE staff

listed under dietary and its current number of FTE staff.

The applicant states it will provide certain support and

billing services for the proposed program from its Palm

Beach County offices.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10086)

states it will provide each patient and family with an

interdisciplinary team of its employees and the patient‟s

physician dedicated to providing a high-level of care and


54

assistance to patients and their families. In addition to the

nurse care manager, the patient‟s attending physician and

the medical director, the interdisciplinary team includes a

home health care aide, chaplain, social worker, volunteers,

bereavement coordinator, and on-call nursing team. As



operation.



Community Relations Rep 3.00 3.00

Executive Director 1.00 1.00

Admissions Coordinator 1.00 1.00

Office Manager 1.00 1.00

Receptionist 0.00 0.30

Patient Care Manager 2.00 2.00

Patient Care Secretary 2.00 2.30


RNs 6.00 7.70

LPNs 1.00 3.00

HHAs 4.10 6.70

Clinical Liaison 0.50 2.80

Bereavement Coordinator 0.50 1.00

Spiritual Care Coordinator 1.00 1.20


Manager Continuous Quality

Improvement

0.00

0.30

Dietician 0.20 0.20

Medical Social Worker 2.00 2.20


(b) Expected sources of patient referrals.

Compassionate Care Hospice of Florida, Inc.

(CON #10083) states that referrals will come from area

physicians, hospitals, nursing homes, other healthcare

providers, family members and patients themselves. The

applicant received a number of letters of support from

hospice Service Area 10 physicians, assisted living facilities,

nursing homes, hospitals, other community organizations

and residents. Douglas Gardens of Broward County, Inc. (CON #10084)

states it will offer more outreach and education, more hope

for well directed care to timely hospice care within the

service area. Douglas Gardens expects referrals from the

following entities: nursing homes, hospitals, assisted living

facilities, comprehensive medical rehabilitative facilities,


55

long-term care hospitals, physicians, families, individuals,

advocates for the homeless, advocates of AIDS and HIV+

groups, and military related organizations within the area.

Hospice of Palm Beach County, Inc. (CON #10085) will

target a variety of sources for hospice referrals, such as:

physicians, hospital discharge planners, social workers,

nursing facilities, assisted living facilities, home-health

agencies, community social service agencies, churches and

veterans groups.

Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10086) will

actively seek patient referrals throughout the community

and anticipates that referrals will originate from physicians,

long-term care facilities, including nursing homes, assisted

living facilities and adult care centers, hospitals,

patients/patient families, managed care companies, and

insurance companies.

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

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


(CON #10083): The following table delineates the number of

admissions by payer type for the first two years of operation.

Expected Admissions by Payer Type

For Compassionate Care Hospice of Florida, Inc. Service Area 10

Payer Type Year One Year Two

Medicare 160 429

Medicaid 5 14

Self-Pay 0 0

Charity 2 6

Insurance 3 8

Total 170 456

Source: CON Application #10083, page 97.

As shown in the table above, the applicant intends to serve

170 and 456 patients in its first and second year of

operation respectively. It is noted that the applicant‟s

provision of Medicare will comprise 94.1 percent of


56

admissions during the first two years of operations, while

Medicaid, self-pay, and charity will each comprise 5.88

percent of admissions in year one and 6.14 percent in year

two.

Compassionate Care indicates that charity care will be 1.3

percent of admissions in years one and two. Year one

computes to Medicare 94.11 percent, Medicaid 2.94 percent,

insurance 1.76 percent and charity care 1.17 percent of total

admissions. Year two percentages compute to Medicare

94.07 percent, Medicaid 3.07 percent, insurance 1.75

percent and charity care at 1.31 percent. Douglas Gardens of Broward County, Inc. (CON #10084)

provided the following table illustrating its projected number

of admissions by payer type for the first two years of

operation.

Projected Number of Admissions by Payer Type For Douglas Gardens of Broward County, Inc.

Service Area 10 Payer Type Year One Year Two

Medicare 168 303

Medicaid 19 33

3rd Party Insurance 7 11

Self-Pay 2 2

Uncompensated 6 9

Total 202 358 Source: CON Application #10084, page 2-29.

The applicant projects for year one Medicare will comprise

83.16 percent of admissions, Medicaid 9.40 percent and self-

pay one percent, and uncompensated 2.97 percent. During

year two of operations the applicant projects Medicare 84.63

percent of admissions, Medicaid 9.21 percent, self-pay 0.55

percent, and uncompensated 2.51 percent.

Hospice of Palm Beach County, Inc. (CON #10085)

projects that its admissions by payer type will be similar to

its experience in its existing Palm Beach County operations,

adjusted to account for the experience of the existing hospice

providers in Broward County. The following table illustrates

the projected number of admissions by payer type for the

first two years of operations.

However, the applicant actually provided the payer types by

number of patient days, not admissions.


57

Projected Number of Patient Days by Payer Type

For Hospice of Palm Beach County, Inc. Service Area 10


Medicare 13,778 31,414

Medicaid 672 1,532


Self-Pay 176 416

Total 15,000* 34,200 Source: CON Application #10085, page 113 and Schedule 7B, pages 158-159. *Actual total is 14,901.

It is noted that according to the applicant‟s Schedule 7B and

Schedule 5 projected utilization assumptions, third-party

insurance will comprise 363 patient days and self-pay 182

patient days for year one which reflects the total patient days

for year one as 15,000.

The applicant indicates that the average length of stay will be

60 days in the above referenced schedules and that “the

assumed average lengths of stay were multiplied by the

projected admissions to determine the projected patient

days” for both years one and two25. Applying this

information to the applicant‟s projected patient days yield

the following.

Projected Number of Admissions by Payer Type



Medicare 230 524

Medicaid 11 26


Self-Pay 3 7

Total* 250 570 Source: CON Application #10085, based on information on page 85, Exhibit 29 on page 87, Schedule 5 assumptions on page 154, and Schedule 7B, pages 158-159. *Totals add to 249 and 571 and do not foot due to rounding.

The applicant projects for years one and two Medicare will

comprise 91.9 percent of patient days, Medicaid 4.5 percent,

third-party insurance 2.4 percent and self-pay/other 1.2

percent. These are the exact same percentage of admissions

for year two. Year one admissions compute to Medicare 92.0

percent, Medicaid 4.4 and third party insurance 2.0 percent

of the total. Self-pay admissions remain 1.2 percent for

years one and two. Differences between year one and two

percentages are due to rounding.

25 CON Application #10085 pages 85, 87 and 154.


58

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, (CON #10086):

The following table delineates the number of admissions by

payer type for the first two years of operation.

Expected Admissions by Payer Type

For Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida

Service Area 10 Payer Type Year One Year Two

Medicaid 7 12

Medicare 208 381

Commercial/Charity/Other 9 17

Total 224 410


The applicant projects for year one Medicare will comprise

92.85 percent of admissions, Medicaid 3.12 percent and self-

commercial/charity/other 4.01 percent. During year two of

operations the applicant projects Medicare 92.92 percent of

admissions, Medicaid 2.92 percent, commercial/charity/

other 4.16 percent.

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

illness, for the first two years of operation.


(CON #10083) provided the following table illustrating the

projected number of admissions by type of terminal illness

for the first two years of operation.

Projected number of Admissions by Diagnosis

For Compassionate Care Hospice of Florida, Inc. Service Area 10

Disease Year One Year Two

Cancer 64 173

Cardiac 34 91

Respiratory 18 50

Renal Failure 20 56

HIV/AIDS 8 14

Other 26 72

Total 170 456 Source: CON Application #10083, page 97.

The applicant projects to serve 170 patients in year one and

456 patients in year two.


59

Douglas Gardens of Broward, Inc. (CON #10084) provided

the following table illustrating the projected number of

admissions by type of terminal illness for the first two years

of operation.


For Douglas Gardens of Broward, Inc. Service Area 10


Cancer 70 125

Other 132 233

Total 202 358 Source: CON Application #10084, page 2-29.


358 patients in year two. The applicant states that terminal

illnesses that will be served are difficult to predict; however

based upon its national experience the following table is

provided for the second year of operations for the proposed

project.

Numbers of Admissions by Disease Category

Disease Category

10/1/08 – 11/30/09 Distribution

Second Year Forecast for New Hospice

Neoplasms 35.1% 126

Circulatory System 14.9% 53

Symptoms & Ill-defined conditions 13.8% 49

Mental Disorders 12.3% 44

Respiratory System 8.5% 30 Nervous System & Sense Organs 6.4% 23

Genitourinary System 3.5% 13

Digestive System 2.2% 8

Infective & Parasitic DX 1.9% 7

Congenital Anomalies 0.4% 1

Injury & Poisoning 0.2% 1

Common Procedure Codes 0.2% 1

Blood and Blood Forming Organs 0.1% 0 Endo, Nutrition/Metabolism DX 0.1% 0

Total 100.0% 358

Source: CON Application #10084, page 2-30.


provided the following table illustrating the projected number

of admissions by type of terminal illness for the first two

years of operation.




Cancer 89 203

Other 161 367



60



Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, (CON #10086)

provided the following table illustrating the projected number

of admissions by type of terminal illness for the first two

years of operation.


For Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida

Service Area 10 Disease Year One Year Two

Cancer 67 123

Alzheimer‟s/Dementia 29 53

CHF 40 74

COPD 20 37

Renal 20 37

Liver/Other 41 74




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

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


(CON #10083) provides the following table for the projected

number of admissions by age cohort.

Projected Admissions by Age Group for

Compassionate Care Hospice Florida, Inc. Service Area 10

Under 65 Over 65 Total

Year One 26 144 170

Year Two 68 388 456


Douglas Gardens of Broward, Inc. (CON #10084) provides

the following table for the projected number of admissions by

age cohort.


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Douglas Gardens of Broward, Inc. Service Area 10


Year One 33 170 202

Year Two 58 300 358

Source: CON Application #10084, page 2-29.


provides the following table for the projected number of

admissions by age cohort.


Hospice of Palm Beach County, Inc. Service Area 10


Year One 42 208 250

Year Two 94 476 570



provides the following table for the projected number of

admissions by age cohort.


Hospice of Palm Beach County, Inc. Service Area 10


Year One 22 202 224

Year Two 41 369 410


(f) Identification of the services that will be provided

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

The hospice care team shall directly provide the following

core services: nursing services, social work services, pastoral

or counseling services, dietary counseling, and bereavement

counseling services. Physician services may be provided by

the hospice directly or through contract. A hospice may also

use contracted staff if necessary to supplement hospice

employees in order to meet the needs of patients during

periods of peak patient loads or under extraordinary

circumstances.


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(CON #10083) states it will provide the core services

(physician services, nursing services, social work services,

dietary counseling, pastoral and counseling services, etc.)

directly through hospice staff and volunteers.

Compassionate Care states it intends to also offer non-core

services that will be provided through contractual

arrangement such as: massage therapy, music therapy,

energetic care, sacred spaces, guided imagery, reminiscence

therapy, pet therapy, aroma therapy, reflexology,

hypnotherapy, life enhancement services and homemaker

services.

Douglas Gardens of Broward, Inc. (CON # 10084) states it

will provide the core services (nursing, social work, pastoral

or counseling services, dietary and bereavement). Douglas

Gardens states a medical director will be employed meeting

the licensure requirements as a hospice physician. The

proposed hospice will contract for such services as: IV

therapy; physical, speech and occupational therapy; patient

transportation; mobile and fixed site X-ray; radiation and

related oncological treatments; nursing home and ALF

patient services; numerous laboratories; emergency and

outpatient hospital services; and backup pharmacy and

medical equipment service.

Hospice of Palm Beach County, Inc. (CON #10085) states

it will provide all core services directly by hospice staff and

volunteers: nursing services, social work services, pastoral

and counseling services, dietary counseling, bereavement

counseling services, home health aides, pharmacy services,

supplies and durable medical equipment, homemaker and

chore services, and physician services. The applicant states

that physical, occupational and speech therapy; patient

transportation services; and infusion therapy will be

provided through contractual arrangement. Other services

such as daycare, handyman services, alternative therapies,

or funder ceremonies may be provided directly, if the

requisite skills are available among Hospice of Palm Beach

County staff or volunteers, or they may be purchased on an

as needed basis from reputable providers.


63


states that with the exception of physicians and a minimal

level of contract care provided by physical, speech, or

occupational therapists, the vast majority of hospice services

will be provided by the hospice care team, including

volunteers. Odyssey states that its interdisciplinary team

case manager is a registered nurse who assesses the needs

of the patient and family and develops a specific plan of care

with the physician. The case manager coordinates care

while the patient‟s physician works with the hospice‟s

medical director and other team members to assure that

symptoms are controlled, pain is managed and the patient

and family are informed.

Odyssey states its interdisciplinary team will include: home

health aide who will provide direct patient care such as

dressing and personal hygiene; chaplain who addresses the

spiritual concerns of patients and family members; social

worker who helps with a wide variety of psycho-social needs

of patients and families ranging from financial

considerations to accessing various community agencies for

additional support programs; volunteers who provide

companionship and non-medical services; bereavement

coordinator who provides support groups, newsletters and

referrals to community services; and on-call nursing team.

When needed, the applicant states additional contract

services such as physical, speech or occupational therapists

will be determined on an individual basis by interdisciplinary

team consultation with the patient, family and attending

physician.

(g) Proposed arrangements for providing inpatient care.


(CON #10083) states that inpatient care services will be

provided through contractual arrangements with existing

nursing homes and hospitals within HSA 10.

The applicant provided evidence of local support for the

project and its ability to secure contracts for services in

Appendix 5 of the application. This evidence of local support

and willingness to contact for inpatient hospice services was


64

received from Plantation General Hospital, Kindred Hospitals

South Florida, Southern SNF, The Forum at Deer Creek and

Park Summit.

Douglas Gardens of Broward, Inc. (CON #10084) states

that for the first two years of operation it expects to provide

inpatient services through contracts with hospitals and if

beds are available, with nursing homes. The applicant

provided a letter from Pompano Rehabilitation and Nursing

Center stating its willingness to enter into a contractual

agreement for inpatient beds.

Hospice of Palm Beach County, Inc. (CON #10085) will

initially arrange for provided inpatient care through

contractual arrangements with hospitals and nursing

homes. Hospice of Palm Beach County has letters of intent

from Northwest Medical Center, West Broward Nursing and

Rehab Center, Life Care Center at Inverrary, Seaview

Nursing and Rehabilitation Center, Broward Nursing &

Rehabilitation Center, Harbor Beach Nursing and

Rehabilitation Center, Hillcrest Nursing and Rehabilitation

Center, The Health Center of Coconut Creek and Fort

Lauderdale Health and Rehabilitation Center to contract for

the provision of inpatient beds.

Odyssey HealthCare of Collier County, Inc. d/b/a

Odyssey HealthCare of Central Florida (CON #10086) will

arrange for inpatient care through contractual agreements

with hospitals, nursing homes and other appropriate

settings. Odyssey included in its application (Appendix R)

letters of support that indicate intent to enter into general

inpatient agreements for hospice care from Westside

Regional Medical Center, Plantation General Hospital, West

Boca Medical Center, Kindred Hospital South Florida-Fort

Lauderdale, Kindred Hospital South Florida-Hollywood,

South Florida State Hospital and Hialeah Hospital. However,

West Boca Medical Center is in District 9 and Hialeah

Hospital is in District 11.


65

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

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

The applicants indicate that they will contract with hospitals

and nursing homes but do not provide specific numbers of

inpatient beds their programs will utilize in these facilities.

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


(CON #10083) states that one or more of the following

clinical criteria should be present for the hospice patient to

be considered appropriate for admission to general inpatient

care:

Pain:

o Investigation to define appropriate treatment

modality

o Active treatment to control pain, which may

include change in medication and/or the routes

of administration

o Titration of medications that cannot be done

safely at home

o Need for advanced technology for analgesic

administration, i.e., IV narcotics

Other Symptoms:

o Death is imminent and care requires ongoing

and frequent skilled nursing intervention

o Symptoms fail to yield to home management or

furnishing the needed care at home is no longer

feasible

o Severe anorexia/and or inability to swallow

necessitating alternative nutritional support

o Fluctuating/deteriorating mental status

necessitating titration of medications, change in

environment or consultation and intervention by

psychologist or psychiatrist


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o Severe shortness of breath or respiratory

distress; intractable nausea or vomiting; open

lesions requiring frequent professional care;

unstable or multiple pathological fractures;

other complicated care that cannot be provided

in the home setting

o Need for continued close monitoring of unstable

recurring medical conditions, i.e. hemorrhage,

severe anemia, severe hypertension, unstable

diabetes, recurrent seizures, etc.

Psychosocial Pathology: evaluation of disturbed mental

status; depression, anxiety in the extreme; and perception

and/or understanding that responds more positively in a

comprehensive care setting that is reassuring, safe

and/or therapeutic.

Compassionate Care states that it will provide respite care

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

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

maximum of five days per respite admission for a

Medicare/Medicaid patient. For patients covered by other

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

time.

Douglas Gardens of Broward, Inc. (CON #10084) will

provide inpatient level of care in a contracted hospital or

nursing home and will use the inpatient bed for pain control,

symptom management and respite purposes for the hospice

patient. A discussion of the applicant‟s admissions

procedures follows.

Douglas Gardens will inform the patient and/or

representative of the availability of short-term inpatient

care for pain control, symptom management and respite

purposes.

Inpatient care for pain and symptom management is

furnished in a facility which provides 24-hour nursing

services.

Respite care may be provided only on an occasional basis

and for no longer than five days at a time.


67

Inpatient provider must have policies consistent with

those of the hospice and must agree to abide by the

patient care protocols established by the hospice.

Douglas Gardens respects the patient‟s right to refuse to

talk to persons not associated with its organization or not

directly involved in the patient‟s care.

When a facility provides short-term inpatient care there

will be a written agreement that specifies: Douglas

Gardens will maintain responsibility for the care of the

patient; supply the provider with a copy of the patient‟s

plan of care; notification of changes in the patient‟s

condition and/or new orders; provider agrees to abide by

the palliative care protocols and plan of care established

by Douglas Gardens; copies of inpatient services,

discharge summary, and inpatient clinical record be

made available to Douglas Gardens at time of discharge;

contracted entity will obtain criminal background checks

on contracted employees who have direct contact or

access to patient records; facility has a designated person

who is responsible for the implementation of the

agreement; Douglas Gardens retains responsibility for

ensuring that the training of personnel who provide

patient care in the inpatient facility; and a method for

verifying that these requirements have been met.

Inpatient days used by Medicare beneficiaries who elect

hospice coverage in a 12-month period to a particular

hospice will not exceed 20 percent of the total number of

hospice days consumed in total by this group of

beneficiaries.


that inpatient care is dictated by a patient‟s medical need

and if possible symptoms are addressed in the patient‟s

home environment. Occasionally this is not possible due to

the nature of the symptoms, the level of care giving support

available, or patient or family wishes. The applicant states

that admission to a general inpatient bed is based on one or

more of the following:


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pain control;

symptom control;

imminent death with symptoms necessitating frequent

physician and nursing intervention;

medical-surgical procedures or therapies aimed at

palliation of symptoms;

family education needs necessary in order to follow the

established plan of care at home;

provision of a safe supportive environment during

periods of acute psychosocial or spiritual breakdown of

the primary caregiver; and

primary caregiver incapable of continuing daily care in

the home setting.

Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, (CON # 10086)

states that inpatient care is provided in the patient‟s “home”

setting; although occasionally this is not possible due to the

need to manage acute symptomology that cannot be

effectively managed in the home setting, or patient or family

wishes. At this point, patients are encouraged to seek the

level of care with which they are most comfortable, including

inpatient hospice care. Odyssey will secure inpatient

contracts with hospitals and nursing homes within the

service area. However, the applicant states it strives to allow

the patient to remain in their home setting at all times (if so

desired by the patient) and is committed to providing the

services required to minimize the need to utilize inpatient

care.

(j) Provisions for serving persons without primary

caregivers at home.

Compassionate Care of Florida, Inc. (CON #10083) states

it is committed to serving all patients including those who do

not have primary caregivers at home. Compassionate Care

Hospice states it will admit patients to its hospice service

even if the patient does not have a caregiver at home. In

2009, the applicant states that 8.5 percent of its patients

lived alone without a caregiver; another 3.3 percent lived

with a compromised caregiver. Compassionate Care Hospice

states that if a patient does not have a caregiver it may

recommend placement in an assisted living facility or

nursing home, in which the hospice program would provide


69

residential care. The applicant states it will assist patients

without financial resources to obtain residential care in a

hospice unit within an ALF or nursing home.

Douglas Gardens of Broward, Inc. (CON #10084) expects

that some persons will not have a designated person who

can function as a primary caregiver; the hospice team leader

will identify and direct safe and effective provision of hospice

care in situations where the terminally ill patient requires

assistance with self-care and skilled services. According to

the applicant, care will be provided in a location in

accordance with the patient‟s wishes.

The applicant states that as decline in functional ability

develops with progressive disease, the type of assistance

needed will be determined by the interdisciplinary team in

collaboration with the patient and family (if involved) and the

following potential solutions will be explored and

implemented:

a. Friends, neighbors and community members as a

potential support network. The hospice team will

provide support, management, teaching, oversight and

emergency intervention to this network if one is

identified

b. Placement in group home, public housing shelter or

skilled nursing facility

c. Continuous care if pain and symptoms are

unmanageable by arranged caregiver support and the

patient desires to remain at home

d. Placement in a general inpatient bed when pain and

symptoms are unmanageable at home


the Helping Hands program is specifically designed to assist

persons without primary caregivers, and to augment the

services of those support networks that are available to the

patient or family. Hospice of Palm Beach County states that

for those without a suitable primary caregiver at home, an

appropriate caregiver network will be sought from among

neighbors, nearby relatives and friends who are capable of

providing supervision and assistance to the patient within

the patient‟s or caregiver‟s home. If there are few qualified

caregivers or if 24-hour care giving is required, qualified

sitter services may be recommended or placement in an


70

assisted living environment or nursing home may be

appropriate. With regard to homeless persons who qualify

for and desire hospice care, the applicant states it will seek a

temporary residential placement at one of the area shelters,

or in an ALF or nursing home as appropriate. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida (CON #10086)

states it will provide services to all patients who meet the

criteria for admissions to hospice. This includes patients

who do not have a primary care giver at home, the homeless

and patients with AIDS. Odyssey‟s non-discrimination policy

adopted by the applicant states:

Odyssey offers palliative care to terminally ill patients and

support to those patients and their families without regard for

diagnosis, gender, sexual orientation, national origin, race,

creed, disability, age, place of residence or ability to pay.

Odyssey states that in the event a patient is impaired and

can no longer be managed at home, or the patient is

homeless, they will be evaluated by an Odyssey nurse for

possible inpatient admission to a hospital or long-term care

facility.

(k) Arrangements for the provision of bereavement services.


(CON #10083) states its bereavement services policy is to

provide appropriate and coordinated bereavement services

and counseling to families and caregivers for at least 13

months following the death of the patient. In addition to

providing services to family and caregivers, services may be

provided to residents and staff of SNFs, ALFs and other

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

patient‟s death. Bereavement services will begin with an

initial bereavement risk assessment to be completed by the

social worker, bereavement coordinator or designee within

five days of admission. Compassionate Care Hospice states

that the bereavement coordinator may also provide

supportive counseling prior to the death of the patient.

Within three to five weeks after the patient‟s death, the

bereavement follow up assessment is completed by the

bereavement counselor following the patient‟s

family/caregiver. The applicant states it also provides


71

bereavement support for children, called Compassionate

Courage. The children participate in art, reading, poetry,

writing exercises, group discussions, drawings, memory

collages, a “feeling toss” game and books. The applicant‟s

additional material does not describe the “feeling toss” game

but it appears “feeling loss” would be the appropriate title.

Douglas Gardens of Broward, Inc. (CON #10084) takes the

provision of bereavement services as a core service that must

be provided to complete the circle of care. The applicant

states it will provide bereavement support to the patient and

family before and following the patient‟s death in order to

minimize the adverse effects of the natural grief process and

to recognize the symptoms of complicated grief. Douglas

Gardens lists the following as a part of its bereavement

services:

Bereavement services will be offered for not less than 13

months after a patient‟s death.

Bereavement services will be goal oriented, based on

assessed needs and approved by the interdisciplinary

team.

Bereavement services will vary dependent upon degree of

risk assessed by members of the interdisciplinary team.

Services include bereavement calls and mailings, visits,

support groups and/or referrals to community resources.

Specially trained volunteers in addition to the

interdisciplinary team may participate in the delivery of

bereavement services.

All bereavement services will be documented.

Douglas Gardens will host at least one memorial service

per year for bereaved family members and significant

others.

Douglas Gardens will provide bereavement services to the

community and to residents of a facility when appropriate

and identified in the bereavement plan of care.

Douglas Gardens‟ staff will receive bereavement and

grief/loss education during orientation and periodically

throughout the year.

The notice of privacy practices is given to bereaved family

members and community members if treatment is

provided.


72

Hospice of Palm Beach County, Inc. (CON # 10085) states

it has extensive policies and procedures in place for the

provision of bereavement services. The patient, caregiver(s),

and family are assessed for coping skills and bereavement

risk factors periodically throughout the relationship with

them including:

In the nurse admission assessment

In the primary nurse‟s, chaplain‟s and social worker‟s

initial assessment

In the ongoing assessment with each team member

contact

At the time of death

Upon referral to the bereavement center

Ongoing, as client continues to receive services

All families that are interested are referred to the

bereavement center after initial follow-up contact by the

team, inpatient or admissions social worker. The applicant

also states that all families or affected parties will receive

follow-up cards and telephone messages of caring at the

following time intervals one, three, six, and nine months

after the death and within the one year anniversary of the

death month. In addition, Hospice of Palm Beach County

states the following services are provided through the

bereavement center:

Individual and family grief support

Anticipatory grief support for children and teens

Grief support groups

“The Nature of Grief” workshop series

School support groups

SHARE pregnancy and infant loss program

Memorial services

Coping with the holidays program

Sea Star Retreat

Community outreach

Pet loss group

Resource materials

Referrals

The applicant states its initial office will be located in the

Coral Springs area and will have space for counseling and

bereavement activities, and space will be arranged in other

locations to meet and access needs of the community or


73

specific space requirements of various programs as they

develop. Hospice of Palm Beach County commits to provide

bereavement services beyond the 13 months required by law.


states it will continue to care for the family after the patient‟s

death. Odyssey‟s bereavement services begin with initial

assessment upon admission of the patient. An RN assesses

the possible needs of the patient and /or family members

who may have grief/anticipatory issues. Odyssey offers:

condolence correspondence; written materials, articles, and

resources; one on one counseling; bereavement letters; grief

support groups; memorial services; and holiday bereavement

program.

Odyssey states that specific to its Florida programs, it has

been contacted by local hospitals for assistance with the

families of dying patients not on hospice service. While not

reimbursable, Odyssey states its staff has provided

bereavement services to support the family as well as

hospital staff. Odyssey, through the Odyssey VistaCare

Hospice Foundation, offers “SKY Camp‟ which is a free

weekend camp for children ages 7 to 17 grieving the death of

a loved one. Activities at the camp include swimming,

basketball, volleyball, ping-pong and the challenge course.

The course consists of physical challenges designed to

exercise skills for climbing, balancing and teamwork.

Odyssey has conditioned its application to include 0.5 FTE

staff resources for the development of community

bereavement services.

(l) Proposed community education activities concerning

hospice programs.


(CON #10083) states it will provide extensive community

education activities to increase hospice awareness and

utilization. Compassionate Care Hospice staffing include 1.5

FTE professional relations coordinators and 1.0 FTE

community liaison in both years one and two of operation.

According to the applicant, these individuals will be

responsible for leading the Hispanic outreach program,

further developing relationships throughout the Jewish

community and coordinate educational sessions,


74

presentations and other outreach activities throughout the

HSA 10 community. These representatives will educate

nursing homes and assisted living facilities on the myths

and benefits of hospice. The applicant states it will host

hospice educational events at senior organizations, religious

affiliated groups, veterans organizations, and health fairs in

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

holistic end-of-life care through hospice.

Douglas Gardens of Broward, Inc. (CON #10084) states the

„Circle of Community Link‟ will ensure widespread

community outreach to every municipality. Printed material,

commercial spots on television and radio, articles in

newspapers and magazines, testimonials in person at service

clubs, women‟s clubs, churches, synagogues, and schools,

community colleges and universities all produce education,

increase opportunities for volunteers, and function as

outreach for those who may need hospice care. The

applicant also intends to utilize speakers at schools,

insurance companies and states that it will work with

representatives of human resource departments to explain,

and educate them so that they can answer questions about

hospice. Douglas Gardens states that it will provide

continuing educational courses to nurses for CEU credit for

licensure and any specialized certifications. Opening these

classes to others who are not employees can be used to

continue public education and outreach about hospice, its

services, and how palliative services are used when curative

care is no longer an option.

The applicant states it publishes educational guides and

brochures that are available free of charge. Two examples

are:

Guide for Patients Families and Friends/Enhancing the

Quality of Time, a 24-page publication that provides an

overview of hospice care, benefits, payers and answers

often-asked questions.

Tender Legal CareTM Making Choices in Life and Death by

Susan Riker Dolan – This download or read on the screen

at the website is a comprehensive guide to patients,

families and friends about hospice. It is stated to be easy

to read and organized into several sections that cover the

medical, nursing and legal aspects of end-of-life care.


75


it has an active and effective community outreach and

education program in its Palm Beach County service area

and anticipates extending it into the adjacent HSA 10. The

applicant‟s community relations representatives provide

presentations to the community at large (businesses, health

fairs, churches, schools, libraries, hospitals, sororities, civic

groups, etc.) with specific information about Hospice of Palm

Beach County‟s services and provides a mechanism for

attendees to obtain additional information. Hospice of Palm

Beach County commits to develop and implement programs

focused on improving access to hospice services by those of

Hispanic heritage. Special community education efforts,

clinical care protocols, and bereavement services for families

will be implemented to increase participation in hospice for

groups traditionally underrepresented. The applicant states

it will also create a public education program about the

benefits of hospice care to raise awareness and

understanding of patients and families regarding hospice

care as an end-of-life option. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey HealthCare of Central Florida, (CON #10086)

states it will implement a community education plan

designed to address the specific needs of the local residents

and patient referral sources in the market area and promote

the quality, responsive and comprehensive service that it will

provide to patients and their families. Community education

representatives will identify local hospice needs and develop

relationships with patient referral sources by providing

hospice education to the community as well as educating

groups of physicians, social workers, nurses, hospital

discharge planners, assisted living facility personnel and

nursing home personnel regarding hospice care in general

and the applicant‟s specific services.

The applicant states it will conduct local educational

campaigns that promote hospice care and seek to increase

public awareness of hospice care. These topics would

include:

Hospice and Medicare regulations

Pain management

Advance directives

Personal perspectives on dying


76

Grief and loss

Symptom management

Alzheimer‟s disease and hospice

Is my patient appropriate for hospice?

Stress management

Odyssey anticipates hosting a seminar for clergy and

community faith leaders focused on the classical and

contemporary theories grief, mourning, and death and dying.

(m) Fundraising activities. Compassionate Care Hospice of Florida, Inc.

(CON #10083) states that Compassionate Care Hospice has

a relationship with Compassionate Care Hospice

Foundation, an unrelated not for profit 501c3 organization,

whose mission is to provide the resources necessary to

support the extraordinary needs of hospice patients and

their families. The applicant states that Compassionate Care

Hospice does not actively raise funds from the community

but if an individual wants to make a charitable donation,

Compassionate Care Hospice of Florida will direct those

individuals to Compassionate Care Hospice Foundation‟s

website.

Douglas Gardens of Broward, Inc. (CON #10084) states

that fundraising and donations cannot be counted upon as a

steady revenue stream, therefore it will work diligently to

negotiate rates with insurers, HMOs, PPOs, and other local

and state programs to cover the cost of care. The applicant

discusses the following methods of fundraising: a non-profit

foundation, sponsorship, a special day of the week event, i.e.

“hospice day”, partnerships, corporate gift giving, and local

community appreciation. Other events that the hospice may

sponsor directly include: golf tournaments, fishing

tournaments, raffles, concerts, and a host of other activities

as possible venues for fund raising. The applicant states it

will strive to be outstanding in the care it provides, in its

community partnership, and with its patients, their families,

friends, the employees and volunteers, thus anticipating

donations to come even when no regular or directed fund-

raising campaign is undertaken.


77


that alternative funding sources will be necessary to

supplement Medicare, Medicaid, private and other

reimbursement sources, and like most hospice programs it

will rely upon these alternative sources of funding to help

subsidize its operations. The applicant states it undertakes

a variety of fundraising activities: contributions, bequests,

endowments, memorials, and restricted donations from

families, friends and others who have been positively

impacted by the applicant‟s services or believe in and

support its activities. Hospice of Palm Beach County states

that it sponsors, participates in, or otherwise supports a

wide array of community benefit events such as golf

tournaments, walk-a-thons, and auctions. Hospice of Palm

Beach County also has a resale shop in which donated items

are sold.

The applicant states that it anticipates charitable

contributions will initially constitute a smaller proportion of

overall income in HSA 10, as a presence is established and

recognition increases in the community. This application is

conditioned on establishing a new foundation for Broward

County to meet the needs of its residents and to providing

one million in initial funding for its establishment. The

applicant intends to model its fundraising activities in HSA

10 to those it currently implements in Palm Beach County.


states it will not perform any local fundraising activities in

direct support of its operations. All program services and

activities will be funded by the hospice‟s operations. The

applicant states it will support existing community-based

fundraising efforts including fundraising efforts of local

health care support groups and the existing hospice

providers as well as fundraising efforts of the Dream

Foundation. The applicant states that its program will have

no impact on the fundraising activities of the local existing

providers.

The applicant‟s parent company, Odyssey HealthCare has a

foundation function called the Odyssey VistaCare Hospice

foundation. The Foundation‟s mission is to support and

educate persons and organizations dealing with life limiting

illnesses. The applicant states that the Foundation makes


78

contributions to organizations nationally and to

organizations in the communities Odyssey serves. Each year

gifts from the Odyssey VistaCare Hospice Foundation

support end-of-life initiatives and other causes. The

applicant states that Odyssey‟s annual community program

includes: providing charity hospice care for needy patients;

providing assistance to patients and families when their

financial circumstances prevent them from covering basic

needs; and providing financial contributions to non-profit

agencies. The applicant states that non-reimbursable

services/expenses are paid for by Odyssey, not by local

contributions.

3. Statutory Review Criteria

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

Need for an additional hospice program is evidenced by the availability,

accessibility and extent to utilization of existing health care facilities and

health services in this service area. The co-batched applicants are

responding to published need of one hospice program in Hospice Service

Area 10.

The following chart illustrates hospice admissions for the past five years.

As shown below, admissions have overall decreased from 8,712 in the

year ending December 31, 2004 to 8,260 in the year ending December

31, 2009.

Hospice Admissions for Service Area 10

Calendar Years 2005-2009 Calendar Year Admissions

2009

2008

2007

2006

2005

2004

8,260

8,156

8,355

8,277

8,587

8,712 Source: Agency for Health Care Administration Florida Need Projections for Hospice Programs, 2004-2009.


79

Compassionate Care Hospice of Florida, Inc. (CON #10083) agrees

with the Agency‟s bed need computation as it indicates a need for one

additional hospice program in Service Area 10. The applicant states that

there is a projected need for 1,849 additional hospice program

admissions for the July 2011 planning horizon. The applicant asserts

that such need exists because of a rapidly growing Hispanic population.

Compassionate Care Hospice of Florida states that Broward County‟s

overall population is now 24 percent Hispanic while some western

suburbs such as Miramar are 40 percent Hispanic. By 2014, the

applicant states that the Hispanic population in Broward County will be

29 percent and 44 percent in Miramar. Since 1999, Hispanic deaths

have increased in Broward County by 95 percent. Also according to the

applicant, during the past three years Hispanic deaths have increased

more than 11 percent while non-Hispanic deaths have actually decreased

3.5 percent.

Compassionate Care Hospice of Florida states that Hispanics are less

likely to seek and receive healthcare services, which might contribute to

their poorer heath status and higher rates of morbidity and mortality,

particularly at a younger age. The cultural disparities between Hispanics

and non-Hispanics are apparent in the tendency for the terminally ill to

not utilize end-of-life care. The applicant states it has the skill set to

admit, manage, and treat Hispanic patients in a most culturally sensitive

way to enhance overall hospice penetration amongst Hispanic terminally

ill residents. The applicant states that in areas with Hispanic

population, particularly throughout its existing programs in the

northeastern United States, Compassionate Care Hospice hires Spanish

speaking staff including nurses, aides, chaplains and others. The

applicant states it will enhance accessibility, availability and utilization

of Broward County‟s Hispanic population as well as all other residents of

the county. Relative to its entrance into the service area, the applicant

states it will not impair the volume of the existing hospices.

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

Compassionate Care Hospice, is in compliance with the conditions of

participation for hospice providers of services under the Health

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

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

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

Medicare conditions of participation as well as Florida hospice licensure

requirements. Compassionate Care Hospice of Florida has also

conditioned the application to specific operational conditions to

demonstrate its quality care and patient enhancement activities.


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The applicant states that its parent company Compassionate Care

Hospice has the experience and expertise of developing several quality

hospice programs throughout the nation and with proven policies,

procedures and unique programming in place the applicant will be able

to provide care in the most efficient manner. Compassionate Care states

it will contract for certain services such as durable medical equipment,

pharmaceuticals, medical supplies, recruitment of staff and ambulance

services. Compassionate Care states it will open its main office in a

centrally located area of the county so that the location is efficient and

appropriate for interdisciplinary team members who must travel back

and forth between patient visits and the office.

Douglas Gardens of Broward County, Inc. (CON #10084) states that

availability often refers to how much of a service exists, or how many

facilities exist. In the case of hospice programs, their ability to expand is

based upon how many staff can be employed and how efficient the

programs operate that will fund that expansion.

The applicant states that it will seek accreditation by the Joint

Commission. The applicant states that quality of care for hospices is

also measured by maintaining pain control and it will remain focused on

pain management by providing in-service training for staff and

volunteers. Additionally, the publication of the newsletter, PharmSmart,

is another way of remaining focused on pain management. The applicant

states it will assure quality with its code of conduct26. The applicant also

lists electronic medical record, building partnerships with local health

care facilities, electronic call center, and competency assessment of

patient care staff as ways it can ensure quality. Douglas Gardens states

that it has a “core philosophy made manifest in the delivery of service

and a code of conduct that emphasizes dignity in the treatment of

employees and patients”. Douglas Gardens indicates that when its

philosophy and code of conduct are “put together, the result is better

choices in all practices and enhanced patient care”.

The applicant states that access in hospice is getting information to

everyone, and to gatekeepers, those persons who are likely to help people

make informed decisions about health care services, and who are

familiar with people‟s health care needs - physicians, religious leaders,

social service workers, schools, hospitals, nursing homes, health care

professionals, all represent access points to hospice care. Access is tied

to outreach efforts to make the hospice known to those seeking such

26 Excerpts from Douglas Gardens of Broward, Inc.‟s code of conduct are listed on page 3-3 of CON Application #10084).


81

services. The applicant states that building on long standing

relationships, it has the means to forge new connections throughout

each community to provide education about and access to hospice care.

Hospice of Palm Beach County, Inc. (CON #10085) states that

availability, accessibility, quality of care, and extent of utilization in the

service area will be enhanced as the result of the implementation of its

program, primarily as a result of its experience, capability, and its “Open

Access” policies. Hospice of Palm Beach County states that hospice

penetration rates have been increasing steadily in recent years

nationwide, throughout Florida, and in its existing program in HSA 9C.

Broward County‟s penetration rate has also risen slightly in recent years,

though it experienced a decrease between 2007 and 2008. The applicant

states that this increasing use of hospice services reflects greater

knowledge and acceptance of the hospice philosophy of end-of-life care

among physicians, other health care providers, and the general populace.

The applicant states that substantial barriers and obstacles to access

and availability of hospice services remain for many who could benefit

from them. Hospice of Palm Beach County states it is confident that the

extent to utilization of hospice services still has substantial room for

growth in Broward County. Recognizing, defining, and developing

strategies to overcome remaining barriers and obstacles to access and

availability will be key to continuing, and accelerating, the historic trends

of greater acceptance and use of hospice services. The applicant states

that overcoming these remaining informational and attitudinal obstacles

to acceptance of hospice care among health care providers and potential

consumers requires that resources of a large, strong, experienced and

capable hospice provider. Hospice of Palm Beach County states it has

created multicultural outreach and patient care programs that are

specific to cultural needs and diversity.

In terms of enhancing geographic access to care in Broward County, the

applicant states it will be able to initiate high level services quickly and

efficiently based on its success in the adjacent Palm Beach County,

HSA 9C. The applicant is prepared to implement services in the Coral

Springs area of Broward County by July 2011. The applicant intends to

open a second office in the southwestern region of the county by the first

quarter of the second year of operations, October 2011. The applicant

states it will use its resources and ability as a regional provider to meet

the growing needs of the county and in particular focus on serving the

identified underserved areas geographically.


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HealthCare of Central Florida, (CON #10086) states that existence of

special not normal circumstances in the hospice service area confirms

the need for an additional hospice program to ensure adequate

availability of and access to required hospice care. The special not

normal circumstances were defined as: HSA 10 utilization rate

consistently lower than the state average hospice utilization rate; HSA 10

residents accessed hospice services at a below average rate; and

consistently underserved patient groups: cancer patients under and over

the age 65, non-cancer patients under and over the age of 65 and

Broward County minority population residents.

Odyssey states that since competition between hospice providers is

service-based rather than price-based, the introduction of another

hospice provider will provide the incentive for the existing hospice

providers to improve and expand the level of service provided to residents

of HSA 10. As a result of the new competition, the applicant states that

residents will receive better hospice services. Odyssey states that the

ability to consistently provide responsive, quality service to patients and

their families and to provide a comprehensive array of hospice care

services have been key factors in communities embracing its services.

The applicant states that it has implemented a community education

plan designed to address the specific local needs of the patients and

patient referral sources in that market and will implement a similar plan

to meet the specific needs of the residents of HSA 10. The applicant will

establish two offices within Broward County. The first office will be

located along the I-75 corridor in southwest Broward County. The

second along the I-95 corridor in central/northeast Broward County.

The applicant states that the office locations will provide easy access to

the minority populations of Broward County who have historically used

hospice services to a lesser extent.

The applicant states that it will be held to the same high standards of

efficiency and quality that all Odyssey hospice programs are held to

nationwide. The proposed hospice program will be cost-efficient and

operationally efficient; provide a level of patient-focused care not

currently available and expand the existing hospice market by serving a

broader base of patients in the hospice service area. The applicant states

that two additional areas that Odyssey has been focusing on and that

will benefit HSA 10 are disaster planning and “green” initiatives.


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

the applicant demonstrated the ability to provide quality care? ss. 408.035(1), (c), Florida Statutes.

Compassionate Care Hospice of Florida, Inc. (CON #10083) states it is

committed to providing the highest quality care possible to terminally ill

patients and their families. Compassionate Care Hospice is a newly

formed entity. Although it has received a certificate of need to provide

services in Polk, Hardee, and Highlands Counties, the program is not

expected to be operational until October 2010. As such, the applicant

does not have an operating history in the State of Florida. The applicant

states that through its relationship with its parent company,

Compassionate Care Group, Ltd, which has a 17-year history of

providing quality hospice care it has access to a substantial body of

knowledge, skills and experience in establishing and operating hospice

programs. Founded in 1993, Compassionate Care has 24 hospice

programs and 42 offices in 16 states: New Jersey, Delaware, Kansas,

New York, Massachusetts, Georgia, Texas, South Dakota, Illinois,

Virginia, Pennsylvania, Michigan, South Carolina, Nebraska, Wisconsin,

and Minnesota.

The applicant asserts that it is committed to providing the highest

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

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

demonstrated through its accreditation, staffing standards that surpass

NHPCO and national benchmarks, quality assessment and performance

improvement plan, patient/family satisfaction surveys, staff membership

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

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

measures to reflect its commitment to providing quality services.

Compassionate Care is not a current hospice provider in the State of

Florida and therefore had no voluntary data to report on the Florida

Health Finder, Hospice Provider Family Satisfaction Survey.

Douglas Gardens of Broward, Inc. (CON #10084) is a new entity formed

for the sole purpose of establishing a hospice program in Hospice

program in Service Area 10. Through the collaboration of its share

holders, Seasons Healthcare Management and Miami Jewish Health

Systems, the applicant states it will benefit from the experience of its

shareholders because both possess records of excellence in serve

development and delivery. The applicant states it will seek the Joint

Commission accreditation. In addition to external review and

accreditation, the applicant states that quality is an ongoing focus for


84

maintaining the highest level of care, patient and family satisfaction, and

employee and volunteer pride. The applicant states that it will

demonstrate its commitment to quality of care through membership in

state and national hospice and palliative care organizations, accurate

data reporting, and quality assessment and performance improvement

programs.

Agency records indicate Miami Jewish Health Systems has three entities

subject to certificate of need review, Miami Jewish Home and Hospital for

the Aged, Douglas Gardens Hospital, and Douglas Gardens Hospice.

Miami Jewish Home and Hospital for the Aged had three substantiated

complaints related to administration and personnel, plan of care, and

quality of care/treatment. Douglas Gardens Hospital had no

substantiated complaints. Douglas Gardens Hospice had one

substantiated complaint related to inappropriate discharge. These

complaints were within a three-year period ending July 12, 2010. It is

noted that the applicant did not participate in voluntary reporting

between July 2009 and September 2009, on the Florida Health Finder,

Hospice Provider Family Satisfaction Survey.

Hospice of Palm Beach County, Inc. (CON #10085) states it has a long

history of providing quality care to its patients. Hospice of Palm Beach

County is accredited by the Joint Commission, and accredited as a

Jewish Hospice through the Palm Beach County Board of Rabbis.

Hospice of Palm Beach County is a provider of Medicare and Medicaid

benefits and a member of the National Hospice and Palliative Care

Organization, Florida Hospices and Palliative Care, Inc., National Hospice

Workgroup, and the National Association for Home Care. The applicant

states it was incorporated February 27, 1978, as a not-for-profit agency

and in 1980 has a daily census of 20 patients, and its first two inpatient

beds. In 1981, the applicant states it received a certificate of need and a

license from the Department of Health and Rehabilitative Services.

Hospice of Palm Beach County states it is in good standing with

Medicare and Medicaid and operates in compliance with all federal, state,

and local statutes, regulations, and ordinances. Operating policies,

procedures, practices, and protocols are in place, as are the corporate

performance improvement plan, risk management plan, and utilization

review process. The applicant states it is fully confident in its ability to

extend its existing quality hospice program throughout the neighboring

HSA 10.


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Agency records indicate that Hospice of Palm Beach County, Inc. has no

substantiated complaints for the three year period ending July 12, 2010.

It is noted that the applicant did participate in voluntary reporting

between July 2009 and September 2009, on the Florida Health Finder,

Hospice Provider Family Satisfaction Survey. Hospice of Palm Beach

County had 274 to 367 survey respondents and received five star ratings

(90 to 100 percent satisfaction) in all categories.


HealthCare of Central Florida (CON #10086) is the sole shareholder is

Odyssey HealthCare Operating B, LP, a wholly owned subsidiary of

Odyssey. The parent is stated to have 90 Medicare-certified licensed

hospice programs spread among 30 states. Within Florida, Odyssey has

an operational Medicare and Medicaid-certified hospice program with

locations in HSA 4B (Volusia and Flagler Counties), HSA 11(Miami-Dade

and Monroe Counties), and in HSA 3 (Marion County). Odyssey states

that its Volusia-Flagler SA 4B hospice provided more than 40,000 patient

days of care, Miami-Dade/Monroe SA 11 provided over 96,000 patient

days during calendar year 2009 and Odyssey Marion SA 3B opened

January 2010 and provided 1,161 patient days of care during its first

quarter.

If CON approved, the applicant anticipates establishing and operating its

Service Area 10 hospice with the speed and efficiency that it did when

approved to operate in Service Areas 3B, 4B and 11. The applicant

states that Odyssey hospice programs enjoy membership in the National

Hospice and Palliative Care Organization, and are Medicare and Medicaid

certified (or are pursuing said certification). The applicant says it will

adopt and practice the same standards of quality and efficiency that are

promoted by the parent.

For the three-year period ending July 12, 2010, the parent‟s Odyssey

HealthCare-Daytona, Odyssey HealthCare-Miami/Dade and Odyssey

HealthCare-Marion County, have no substantiated complaints. It is

noted that Odyssey had two hospices that participated in voluntary

reporting between July 2009 and September 2009, on the Florida Health

Finder, Hospice Provider Family Satisfaction Survey. Odyssey

Healthcare Daytona Beach had 20 to 28 survey respondents and received

five-star ratings in all categories. Odyssey Healthcare Miami had 22 to

28 survey respondents and received five-star ratings in three categories,

four stars (80-89 percent satisfaction) in the „hospice team response to

your evening/weekend needs‟ and three stars (70-79 percent satisfaction)

in the „family kept informed of the patient‟s condition‟ questions.


86

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.

Compassionate Care Hospice of Florida, Inc. (CON #10083): The

audited financial statements of the applicant were reviewed to assess the

financial position as of the balance sheet date and the financial strength

of its operations for the period presented.

The applicant is a Florida for-profit corporation and a development stage

company that was formed on September 19, 2007 for the purpose of

operating a hospice in Florida, with net assets of $40,000 and $63,400 in

liabilities (due to affiliate) for the period ended December 31, 2009. The

audit indicates that the applicant is economically dependent upon the

stockholders and an affiliate to provide working capital. At the date of

the audit, no operating results were available. Without results from

operations, an analysis of the short and long-term strength of the

applicant cannot be made.

Capital Requirements:

Schedule 2 indicates total capital projects of $433,700, which consist of

the CON subject to this review, CON #10082 for a hospice in District 8

and CON #10091 for a hospice in District 11. In addition, the applicant

will have to fund the projected year one operating loss of $411,644 and

the combined operating losses of CON #10082 ($520,170) and CON

#10091 ($505,331).

Available Capital:

The applicant provided a letter from its parent corporation,

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

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

applicant included operating results of its parent. However, the

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

gives an independent opinion on whether or not the financial statements

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

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

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

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

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

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

this is consistent with our treatment of unaudited parent financial

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

applicant provided additional independent documentation, namely a line

of credit agreement.


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Staffing:

Position

Average Number of FTE Year One



Professional Relations Coordinator 1.50 1.50

Secretary 1.00 1.00

Community Liaison 1.00 1.00


Registered Nurse 1.00 7.00

Per Diem Registered Nurses 0.80 2.00

Licensed Nurse Practitioners 1.00 2.00

Per Diem Lic‟d Nurse Practitioners 0.00 0.80

Nurses Aides 3.00 14.00

Per Diem Nurses Aides 1.00 1.80

Homemaker 1.00 1.00

Life Enhancement Specialist 1.00 1.00

Continuous Care Per Diem LPN 0.09 0.42

Continuous Care Per Diem Aide 0.09 0.42


Massage Therapist 0.20 0.20

Dietary Services 0.20 0.20



Chaplain 0.50 1.00

Total 16.68 39.99 Source: CON Application #10083, pages 94-95 & Section 3, Schedule 6A.

Conclusion: Funding for this project is in question.

Douglas Gardens of Broward County, Inc. (CON #10084): The audited

financial statements of the applicant were reviewed to assess the



The applicant is a Florida for-profit corporation and a development stage

company that was formed on April 16, 2010 for the purpose of operating

a hospice in Broward County, Florida, with net assets of $1,050,000 and

$0 in liabilities for the period ended May 5, 2010. The cash balance of

$1,050,000 represents the proceeds from issuing common stock. At the

date of the audit, no operating results were available. Without results

from operations, an analysis of the short and long-term strength of the

applicant cannot be made.


88


Schedule 2 indicates total capital projects of $802,715 which consists of

the CON subject to this review. It should be noted that among the

applicant‟s conditions, two conditions indentified a need for specific

funds. Funding for those conditions is included in the capital budget on

Schedule 2. In addition, the applicant will have to fund the projected

year one operating loss of $399,500.

Available Capital:

The applicant provided audited financial statements as of May 31, 2010

showing $1,050,000 in cash with no liabilities. This amount is sufficient

to cover the capital costs prior to opening, but it does not appear

sufficient to cover both the project costs and fund the year one operating

loss. Presumably one of the two members of this entity, Seasons

Healthcare Management and Miami Jewish Health Systems would fund

the working capital needs prior to reaching the projected profit.

However, we did not receive pledges to fund or proof of ability to fund

working capital from either of these entities. We recently evaluated

Miami Jewish Health Systems in expedited CON #10092. In that case we

found funding for the project to be in question. In this case it is not clear

that the funding is or would be made available to fund the year one

operating loss. Staffing:





Team Coordinator 1.00 1.00

Team Assistant 1.00 1.92


Human Resources 1.00 1.00

CC Coordinator 1.00 1.00

Clinical Administrator 1.00 1.00

RNs/LPNs 13.08 19.17

Nurses Aides/HHAs 4.50 6.75

Dietician 0.75 1.00

Chaplain 1.00 1.67



Music 1.00 1.00

Total 31.16 41.51 Source: CON Application #10084, Exhibit 5-2, Schedule 6A, pages 14-15.


89

It is noted that the applicant does not list FTEs for a medical director or

ancillary services on Schedule 6A. However, the applicant assumes a

part-time medical director will be contracted; and that contract

arrangements are expected to be utilized for rehabilitative/palliative

therapy services. Conclusion:

Funding for this project should be available as needed; however,

available funding to support the year one operating loss is in question.

Hospice of Palm Beach County, Inc. (CON #10085): The audited

financial statements of the applicant were reviewed to assess the



The applicant is a Florida not-for-profit corporation and provided a copy

of its audited financial statements for the periods ending September 30,

2009 and 2008. These statements were analyzed for the purpose of

evaluating the applicant‟s ability to provide the capital and operational

funding necessary to implement the project.

Short-Term Position:

The applicant‟s current ratio of 2.3 indicates current assets are more

than two time greater than current obligations. This is slightly above

average and good position. Working capital of $11.6 million is a measure

of excess liquidity that could be used to fund capital projects. The ratio

of cash flow to current liabilities of 0.6 is slightly above average, an

adequate position. Overall, the applicant has a good short-term position.

(See Table below).

Long-Term Position:

The ratio of long-term debt to net assets of 0.3 is below average and

indicates the applicant has sufficient equity to acquire additional debt if

needed, a good position. The ratio of cash flow to assets of 9.0 percent is

above average and a good position. The most recent year had $7.1

million in operating income, which resulted in an 8.0 percent operating

margin. Overall, the applicant has a good long-term position. (See Table

below).


Schedule 2 indicates total capital projects of $6,237,500, which includes

the CON subject to this review and other capital projects. The applicant

is projecting a year one operating loss of $249,534 and an operating loss

in year two of $86,540 for this project. The applicant will have to fund

the operating losses in years one and two until profitability can be


90

reached. In addition, the applicant listed a number of conditions as part

of this application. It is not clear from the information provided if the

financial impact of these conditions were included in the capital cost or

projected operations.

Available Capital:

Schedules 2 and 3 indicate that funding for this and its other projects

will be provided by the applicant‟s cash and investments. The applicant

has cash and current investment of $6.0 million. The applicant has

working capital of $11.6 million and cash flow from operations of $5.2

million. It appears that the applicant has sufficient resources to fund

the entire capital budget, including the proposed conditions, and the

operating cash flow appears sufficient to fund the project‟s projected

operating loss.

Staffing:

Hospice of Palm Beach County anticipates it will recruit, train, and use

volunteer staff at approximately the same proportion of overall staff as

that currently found in its Palm Beach hospice.

Position Average Number of

FTE Year One Average Number of FTE Year Two


Medical Records Clerk 0.50 1.00

Associate Medical Directors 0.50 1.00

RNs 4.00 9.00

Hospice Aides 4.00 9.00

ON-Call Nurse 2.00 3.00

Continuous Care 1.00 4.00

Manager 0.00 1.00

Integrative Therapist 0.50 1.00


Social Workers 2.00 3.00

Bereavement Counselors 0.50 1.00

Chaplain 1.00 1.50

Secretary 0.00 2.00

Courier 1.00 2.00





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The applicant does not provide FTE designation for a registered dietician,

instead the applicant lists 7.10 FTE staff listed under dietary and its

current number of FTE staff. The applicant states it will provide certain

support and billing services for the proposed program from its Palm

Beach County offices.

Conclusion:

Funding for this project should be available as needed.

Hospice of Palm Beach County, Inc.

9/30/2009

9/30/2008

Current Assets (CA) $20,834,913

$13,186,178

Cash and Current Investment $6,040,353

$1,417,275

Total Assets (TA) $57,606,044

$49,354,993

Current Liabilities (CL) $9,224,440

$7,443,907

Total Liabilities (TL) $21,224,440

$19,443,907

Net Assets (NA) $36,381,604

$29,911,086

Total Revenues (TR) $88,847,676

$85,071,050

Interest Expense (IE) $108,158

$291,659

Operating Income (OI) $7,101,818

$3,377,602

Cash Flow from Operations (CFO) $5,196,222

$4,039,045

Working Capital $11,610,473

$5,742,271

FINANCIAL RATIOS

9/30/2009

9/30/2008

Current Ratio (CA/CL) 2.3

1.8

Cash Flow to Current Liabilities (CFO/CL) 0.6

0.5

Long-Term Debt to Net Assets (TL-CL/NA) 0.3

0.4

Times Interest Earned (OI+IE/IE) 66.7

12.6

Net Assets to Total Assets (NA/TA) 63.2%

60.6%

Operating Margin (OI/TR) 8.0%

4.0%

Return on Assets (OI/TA) 12.3%

6.8%

Operating Cash Flow to Assets (CFO/TA) 9.0% 8.2%


HealthCare of Central Florida, (CON #10086): The audited financial

statements of the applicant were reviewed to assess the financial position

as of the balance sheet date and the financial strength of its operations

for the period presented.


92

The applicant is a development stage Delaware for-profit corporation

established in 2006 to operate hospice and related business in Florida.

According to the audit, the applicant has no assets and $418,172 in

accumulated deficit and with no operations.

The applicant provided audited financial statements of its ultimate

parent company Odyssey Healthcare, Inc., and subsidiaries (parent), 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 1.6 indicates current assets are slightly

more than one and a half times current obligations. This is below

average and a slightly weak but adequate position. Working capital of

$100.3 million is a measure of excess liquidity that could be used to fund

capital projects. The ratio of cash flow to current liabilities of 0.5 is

slightly below average, an adequate position. Overall, the parent has an

adequate position. (See Table below).

Long-Term Position:

The ratio of long-term debt to net assets of 0.4 is below average and

indicates the parent has sufficient equity to acquire additional debt if

needed, a good position. The ratio of cash flow to assets of 16.2 percent

is well above average and a strong position. The most recent year had

$66.3 million in operating income, which resulted in a 9.7 percent

operating margin. Overall, the parent has a good long-term position.

(See Table below).


Schedule 2 indicates total capital projects of $2,590,507, which includes

the CON subject to this review and CONs 10068, 10062, and 10071. The

applicant is projecting a year one operating loss of $1,094,833, which

will have to fund until profitability can be achieved. In addition, the

applicant listed a number of conditions as part of this application. The

applicant appeared to include these items as expense in years one and

two of operations.


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Available Capital:

Schedules 2 and 3 indicate that funding for this project will be provided

by the applicant‟s parent company through intercompany loans. The

applicant has working capital of $100.3 million and cash flow from

operations of $81.7 million. It appears that the applicant has sufficient

resources to fund the entire capital budget and the operating cash flow

appears sufficient to fund the project‟s projected operating loss.

Staffing:

Odyssey states it is confident in its ability to fill the necessary staff

positions well in advance of opening and providing ample time for

orientation and other pre-opening requirements. The applicant states

that it has in place effective recruitment and retention policies and

programs to successfully staff and operate its hospice programs.

Odyssey states it has an inter-office transfer policy which provides

existing employees the opportunity to transfer to other Odyssey hospice

locations bringing experienced staff to new hospice locations.

Position Average Number

of FTE Year One Average Number of FTE Year Two

Community Relations Rep 3.00 3.00

Executive Director 1.00 1.00

Admissions Coordinator 1.00 1.00

Office Manager 1.00 1.00

Receptionist 0.00 0.30

Patient Care Manager 2.00 2.00

Patient Care Secretary 2.00 2.30


RNs 6.00 7.70

LPNs 1.00 3.00

HHAs 4.10 6.70

Clinical Liaison 0.50 2.80

Bereavement Coordinator 0.50 1.00

Spiritual Care Coordinator 1.00 1.20


Manager Continuous Quality Improvement 0.00 0.30

Dietician 0.20 0.20

Medical Social Worker 2.00 2.20


Conclusion:

Funding for this project should be available as needed.


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CON #10086--Analysis of Parent Company,

Odyssey Healthcare, Inc., and Subsidiaries

12/31/2009

12/31/2008

Current Assets (CA) $255,829,000

$207,323,000

Cash and Current Investment $128,632,000

$56,043,000

Total Assets (TA) $503,004,000

$460,951,000

Current Liabilities (CL) $155,549,000

$124,894,000

Total Liabilities (TL) $251,844,000

$258,418,000

Net Assets (NA) $251,160,000

$202,533,000

Total Revenues (TR) $686,438,000

$616,050,000

Interest Expense (IE) $6,574,000

$7,430,000

Operating Income (OI) $66,285,000

$31,076,000

Cash Flow from Operations (CFO) $81,650,000

$21,049,000

Working Capital $100,280,000

$82,429,000

FINANCIAL RATIOS

12/31/2009

12/31/2008

Current Ratio (CA/CL) 1.6

1.7

Cash Flow to Current Liabilities (CFO/CL) 0.5

0.2

Long-Term Debt to Net Assets (TL-CL/NA) 0.4

0.7

Times Interest Earned (OI+IE/IE) 11.1

5.2

Net Assets to Total Assets (NA/TA) 49.9%

43.9%

Operating Margin (OI/TR) 9.7%

5.0%

Return on Assets (OI/TA) 13.2%

6.7%

Operating Cash Flow to Assets (CFO/TA) 16.2% 4.6%

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

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

The following applies to all applicants. Each co-batched applicant is

offering a new choice of provider in the hospice service area.

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

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

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

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

for services, namely managed care organizations. Therefore, price

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

managed care plans.


95

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

government payer sources, a new hospice provider is not likely to have

any discernable positive impact on competition to promote quality

assurance or cost-effectiveness. As providers offer new or enhanced

services to patients and families as a means to compete on quality

measures, cost-effectiveness would be impacted since the new or

enhanced services would be offered despite the large percentage of fixed-

priced government payers. In other words, the potential exists for new or

enhanced services to be provided for the same federal and state dollars.

Approval of a new provider in the service area is not likely to result in

price-based competition. However, with price not considered a major

factor, competing hospice programs will likely focus on quality of service

to remain competitive in the market. Therefore, although a new hospice

provider is not likely to have any discernable positive impact on

competition to promote cost-effectiveness, it is likely to have a positive

impact on quality assurance.

Compassionate Care Hospice of Florida, Inc. (CON #10083): The

applicant is projecting 1.7 percent of its patient days from managed

care/commercial insurance payers with 97.0 percent of patient days

expected to come from fixed-price government payer sources (Medicare

and Medicaid), with the remaining 1.3 percent as self-pay/charity.

Douglas Gardens of Broward, Inc. (CON #10084): The applicant is

projecting 5.5 percent of its patient days from managed care/commercial

insurance payers with 94.0 percent of patient days expected to come

from fixed-price government payer sources (Medicare and Medicaid), with

the remaining 0.5 percent as self-pay/charity.

Hospice of Palm Beach County, Inc. (CON #10085): The applicant is




the remaining 1.2 self-pay. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida, (CON #10086): The applicant is




the remaining 2.0 self-pay.


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

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

With the exception of CON #10084, Douglas Gardens of Broward, Inc.,

which failed to include inpatient respite care in its Schedule 7

projections, the following applies to all applicants. Schedule 7 of the

application indicates that the services to be provided are routine home

care, continuous home care, inpatient respite, and general inpatient

care.

The Department of Health and Human Services sets rates for routine

home care, continuous home care, inpatient respite care, and general

inpatient care. The Federal rates were calculated for Broward County,

Florida wage index for Medicare Hospice payments of 1.0499 and inflated

through the appropriate period for each applicant. The average price

adjustment factor used was 2.9 percent per year based on the new CMS

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

Care Cost Review.

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

were multiplied by the calculated reimbursement rate for that service in

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

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

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

summarized in the Table for each applicant below.

Compassionate Care Hospice of Florida, Inc. (CON #10083): For year

two of operations, the applicant projected the following percentage of

total patient days by group: Medicare at 94.0 percent, Medicaid at 3.0

percent, self-pay/charity at 1.3 percent, and commercial insurance at

1.7 percent.

The federal rates were calculated for the Broward County, Florida Wage

Index for Medicare Hospice payments of 1.0499 and inflated through

March 2013.


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The applicant calculated continuous care revenues based on 19.2 hours

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

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

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

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

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

projected gross revenue was 1.11 percent, or $45,218, less than the

calculated gross revenue. This difference is not considered material.

Projected revenue appears reasonable.

The applicant offered 12 conditions to its proposed hospice program.

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

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

applicant included sufficient FTEs to meet this condition.

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

$411,644 for year one to a profit of $568,084 for year two.

Conclusion:

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

working capital, this project appears to be financially feasible.


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HOSPICE REVENUE

CON #10083--Compassionate Care Hospice of Florida, Inc.

Wage Index for Broward County (1.0499)

Wage

Component Wage Index

Adjusted Wage

Amount Unadjusted Component

Payment Rate

Routine Home Care $98.19 1.0499 $103.09 $44.72 $147.81

Continuous Home Care $573.11 1.0499 $601.71 $260.99 **$690.16

Inpatient Respite $80.02 1.0499 $84.01 $67.81 $151.82

General Inpatient $406.94 1.0499 $427.25 $228.80 $656.05

Payment

Rate

Inflation Factor

Year Two

Inflation Adjusted Amount

Patient Days Year 2,

March 31, 2013

Calculated Gross

Revenue

Routine Home Care $147.81 1.072 $158.47 24,079 $3,815,836

Continuous Home Care $690.16 1.072 $739.94 74 $54,756

Inpatient Respite $151.82 1.072 $162.77 25 $4,069

General Inpatient $656.05 1.072 $703.37 368 $258,840

Total 24,546 $4,133,500

From Schedule 7 (Gross) $4,088,282

Difference

-$45,218

Percentage difference -1.11%

** Continuous Home Care is calculated based on 19.2 hours of care rather than 24 hours.

Douglas Gardens of Broward County, Inc. (CON #10084): For year two

of operations, the applicant projected the following percentage of total

patient days by group: Medicare at 85.0 percent, Medicaid at 9.0 percent,

self-pay/charity at 0.5 percent, and commercial insurance and other

payers at 5.5 percent.

As stated above, the applicant did not project any service for inpatient

respite care. The federal rates were calculated for the Broward County,

Florida Wage Index for Medicare Hospice payments of 1.0499 and

inflated through June 2013.


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The applicant‟s projected patient days were 3.9 percent or 920 days more

than the calculated patient days. The applicant indicated using a 2.0

percent inflation rate. If we use the same inflation rate as the applicant,

the difference in calculated days is less than 2.0 percent and considered

immaterial. Operating profits from this project are expected to increase

from an operating loss of $399,500 for year one to an operating profit of

$516,700 for year two.

Conclusion:

Assuming the applicant will be able to fund the year one operating loss

this project appears to be financially feasible.

HOSPICE REVENUE

CON #10084 Douglas Gardens of Broward, Inc.


Wage Component

Wage Index

Adjusted Wage


Payment Rate


Continuous Home Care $573.11 1.0499 $601.71 $260.99 $862.70



Payment Rate

Inflation Factor

Year Two


Gross Revenue Year 2, June-2013

Calculated Patient Days

Routine Home Care $147.81 1.080 $159.63 $3,486,000 21,837

Continuous Home Care $862.70 1.080 $931.71 $532,900 572

Inpatient Respite $151.82 1.080 $163.97 $0 0

General Inpatient $656.05 1.080 $708.53 $323,600 457

Total $4,342,500 22,866

From Schedule 7 23,786

Difference

920

Percentage difference 3.87%

Hospice of Palm Beach County, Inc. (CON #10085): For year two of

operations, the applicant projected the following percentage of total


self-pay/charity at 1.2 percent, and commercial insurance at 2.5

percent.


100

The federal rates were calculated for Broward County, Florida Wage


June 2013.

Based on our calculation, the applicant‟s projected gross revenue was

9.12 percent, or $611,532 less than the calculated gross revenue. This

is a significant understatement and could be caused by a difference in

assumptions on inflation rates and or continuous home care

reimbursement. The applicant did not provide details on these

assumptions so we were not able to determine the reason for the

apparent understatement. In any event, understating revenue is a

conservative assumption and therefore reasonable.

The applicant is projecting a loss in both years one and two. The

anticipated deficits of the project are expected to improve from an

operating loss of $249,534 for year one to a loss of $86,540 for year two.

The applicant included non-operating revenue from donations to show a

positive total margin in year one and two. The applicant also provided a

schedule with the project‟s impact on the entire operations of the

applicant. Even if the applicant were not able to raise the non-operating

revenue listed on Schedule 8, the review of the audited financials of the

applicant indicates the applicant would be able to fund the operating loss

over the first two years.

Conclusion:

This project appears to be financially feasible.


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HOSPICE REVENUE

CON #10085 -- Hospice of Palm Beach County, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate

Inflation Factor

Year Two



December 31, 2012

Calculated Gross

Revenue




General Inpatient $656.05 1.080 $708.53 2,433 $1,723,847

Total 34,200 $7,318,670


Difference

-$611,532



HealthCare of Central Florida, (CON #10086): For year two of

operations, the applicant projected the following percentage of total


self-pay/charity at 2.0 percent, and commercial insurance and other

managed health care at 2.0 percent.

The federal rates were calculated for Broward County, Florida Wage


March 2013.

Based on our calculation, the applicant‟s projected gross revenue was

5.55 percent, or $238,480 less than the calculated gross revenue. The

applicant listed in its notes to Schedule 7 the rates used. The rates

appeared to not have included an increase for inflation. This is a

conservative assumption and is therefore considered reasonable. If the


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applicant used the inflation rate used in our review, the difference would

be immaterial. Operating profits from this project are expected to

increase from a loss of $1,094,833 for year one to a profit of $195,276 for

year two.

Conclusion:

This project appears to be financially feasible.

HOSPICE REVENUE

CON #10086 --Odyssey Health Care of Collier County, Inc.


Wage


Adjusted Wage


Payment Rate





Payment

Rate

Inflation Factor

Year Two



March 31, 2013

Calculated Gross

Revenue




General Inpatient $656.05 1.072 $703.37 492 $346,057

Total 24,565 $4,539,088


Difference

-$238,480


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

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

Each of the co-batched applicants is requesting approval to establish a

new hospice program. There are no construction costs and methods

associated with the proposals.


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g. Does the applicant have a history of providing health services to Medicaid patients and the medically indigent? Does the applicant propose to provide health services to Medicaid patients and the medically indigent? ss. 408.035(1)(i), Florida Statutes.

Compassionate Care Hospice of Florida, Inc. (CON #10083) states

that its parent company Compassionate Care Group, Ltd through its

other Compassionate Care Hospice subsidiaries has a history of

providing health services to Medicaid patients and the medically

indigent. According to the applicant, recent utilization reports from

Compassionate Care Hospice in calendar year 2009 show that

collectively Compassionate Care Hospice programs provided 23,447

Medicaid days representing 3.3 percent of total patient days and 1.8

percent of total patient days to self-pay and charity patients.

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

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

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

two of operations.

Douglas Gardens of Broward County, Inc. (CON #10084) states that its

affiliate, Douglas Gardens Hospice, soon to be Seasons Hospice and

Palliative Care of Southern Florida, Inc. has a history of providing

hospice services to the residents of HSA 11, Miami-Dade and Monroe

Counties. However, the applicant as a start-up company does not have a

history of service to any patients. According to the applicant, during

calendar year 2009 its affiliate Douglas Gardens Hospice provided 23.5

percent of total patient days to Medicaid and 0.5 percent of total patient

days to self-pay and no patient days to charity patients.

The applicant provides the following as its projected payer mix for the

first two years of operations. Schedule 7A shows that self-pay and

uncompensated account for three percent of patient days while Medicaid

accounts for 9.0 percent of total patient days for year one and two

respectively.

Hospice of Palm Beach County Inc, (CON #10085) states it has a

history of providing health services to all patients that require hospice

care, without regard to age, race, ethnic group, diagnosis or ability to

pay. The applicant states that in calendar year 2009 it provided

$1,397,255 in charity care to its hospice patients.


104


first two years of operations. Schedule 7A shows that self-pay/other

account for 1.2 percent of patient days while Medicaid accounts for 4.5

percent of total patient days for year one and two respectively.


HealthCare of Central Florida, (CON #10086) states that nationwide

and in its existing Florida locations in Volusia-Flagler, Miami-

Dade/Monroe and Marion Counties, Odyssey accepts all appropriate

patient referrals and accepts all patients without regard to gender,

national origin, race, creed, sexual orientation, disability, age, and place

of residence or ability to pay. The applicant states that Odyssey

HealthCare provided during calendar year 2009 approximately 57

percent of non Medicare net revenue to Medicaid. Approximately 9.6

percent of the non-Medicare services were provided to indigent/charity

patient‟s during the same calendar year.


first two years of operations. Schedule 7A shows that self-pay/charity

account for 2.0 percent of patient days while Medicaid accounts for 3.0


F. SUMMARY

A fixed need pool was published for a new hospice program in Hospice

Service Area 10, Broward County.

Compassionate Care Hospice of Florida, Inc. (CON #10083) proposes

the establishment of a new hospice program in HSA 10, Broward County.

The applicant is proposing total project costs of $131,800 with year one

operating costs of $1,233,571 and year two costs of $3,467,922.

Compassionate Care proposes 12 conditions. See pages 8 and 9 for an

in-depth description of the applicant‟s proposed conditions.

Douglas Gardens of Broward, Inc. (CON # 10084) proposes the

establishment of a new hospice program in HSA 10, Broward County.


of $3,450,500 and year two costs of $5,712,200.

Douglas Gardens proposes 19 conditions. See pages 10-12 for an in-

depth description of the applicant‟s proposed conditions.


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Hospice of Palm Beach County, Inc. (CON #10085) proposes the

establishment of a new hospice program in HSA 10, Broward County.


of $3,022,967 and year two costs of $6,612,315.

Hospice of Palm Beach County proposes 10 conditions. See pages 13

and 14 for in-depth description of the applicant‟s proposed conditions.


HealthCare of Central Florida (CON #10086) proposes the

establishment of a hospice program in HSA 10, Broward County. The

proposed total project cost is $643,963 with year one operating costs of

$2,550,485 and year two cost of $3,945,271.

Odyssey proposes 18 specific, and four conditions of participation as

required by all Medicare-certified hospice providers. See pages 15-19 for

an in-depth description of the applicant‟s proposed conditions.

Need/Access:

Each applicant is responding to published need for a new hospice

program. Each applicant states that there is unmet need in Broward

County, which ranged from access issues for minority populations

including Hispanics, African-Americans, Haitians, chronically ill patient

populations, terminally-ill patients of small assisted living facilities, to

cancer patients under the age of 65 years, cancer patients over the age of

65 years, non-cancer patients under the age of 65 years and non-cancer

patients over the age of 65 years not having proper access to hospice

services.

All applicants provided statistical data of underserved minority

populations in Service Area 10; however, none document that hospice

care to minority residents is not available or accessible.

All co-batched applicants provided evidence that they have local support

for their proposals to enter the service area. All applicants provided

letters of support from hospitals, skilled nursing facilities, continuing

care retirement communities or assisted living facilities within the

hospice service area. However, HPBC submitted the most letters

indicating a willingness to contract for inpatient hospice service with

nine, Compassionate had six, Odyssey five, and Douglas Gardens

submitted one letter indicating a willingness to contract for inpatient

hospice services.


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All applicants have agreed to measurable conditions, if awarded the

CON, to ensure that its proposed program offers improved access to

hospice care, improved education regarding available hospice services,

and to address any cultural barriers to hospice care in Broward County.

The Agency‟s need methodology that resulted in published need for a new

program in Broward County showed the projected number of admissions

minus the current number of admissions for the July 2011 planning

horizon as 1,849. Hospice of Palm Beach County proposed the largest

program to address this published need:

Total Projected Admissions By Applicant

for Years One and Two CON # Applicant Year One Year Two Both Years

10083 Compassionate Care 170 456 626

10084 Douglas Gardens 202 358 560

10085 HPBC 250 570 820

10086 Odyssey 224 410 634

Source: CON Application #’s 10083, 10084, 10085, and 10086.

Quality of Care:

Each applicant offered evidence of its ability to provide quality care.

As current providers of hospice services in Florida, HPBC and Odyssey

participated in the voluntary reporting on the Florida Health Finder,

Hospice Provider Family Satisfaction Survey; Douglas Gardens, who is

also a current provider of hospice services in Florida, did not participate.

Compassionate Care is not currently operational as a hospice provider in

the State of Florida. Financial Feasibility/Availability of Funds:

Compassionate Care Hospice of Florida, Inc. (CON #10083): Without

results from operations, an analysis of the short and long-term strength

of the applicant cannot be made. Funding for this project is in question.

However, assuming the applicant will be able to acquire funding for

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

feasible.

Douglas Gardens of Broward, Inc. (CON #10084): Without results from

operations, an analysis of the short and long-term strength of the

applicant cannot be made. Funding for this project should be available

as needed; however, available funding to support the year one operating

loss is in question. Assuming the applicant will be able to fund the year

one operating loss this project appears to be financially feasible.


107

Hospice of Palm Beach County, Inc. (CON #10085): The applicant has

good short-term position and long-term position. Funding for this

project should be available as needed. The project appears to be

financially feasible.

Odyssey Healthcare of Central Florida, (CON #10086): The parent

has an adequate short-term position and a good long-term position.

Funding for this project should be available as needed. The project

appears to be financially feasible. Medicaid/Charity Care: Compassionate Care Hospice of Florida, Inc. (CON #10083):

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

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

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

two of operations.

Douglas Gardens of Broward, Inc. (CON #10084): The applicant

provides the following as its projected payer mix for the first two years of

operations. Schedule 7A shows that self-pay and uncompensated

account for three percent of patient days while Medicaid accounts for 9.0


Hospice of Palm Beach County, Inc. (CON #10085): The applicant

provides the following as its projected payer mix for the first two years of

operations. Schedule 7A shows that self-pay/other account for 1.2

percent of patient days while Medicaid accounts for 4.5 percent of total

patient days for year one and two respectively. Odyssey HealthCare of Collier County, Inc. d/b/a Odyssey

HealthCare of Central Florida, (CON #10086): The applicant provides

the following as its projected payer mix for the first two years of

operations. Schedule 7A shows that self-pay/charity account for 2.0

percent of patient days while Medicaid accounts for 3.0 percent of total

patient days for year one and two respectively. G. RECOMMENDATION

Approve CON #10085 to establish a hospice program in Hospice Service

Area 10, Broward County. The proposed total project cost is $842,938

with year one operating costs of $3,022,967 and year two costs of

$6,612,314.


108

CONDITIONS:

1. Hospice of Palm Beach County commits to establish a new

foundation for Broward County to meet the needs of Broward

County residents and to provide $1 million in initial funding for its

establishment. These funds will go towards building a permanent

foundation that will cover the same broad group of programs that

the applicant‟s Hospice of Palm Beach County Foundation covers

today. Compliance will be documented by providing a declaratory

statement to the Agency annually providing the number of

programs and services provided to families in need.

2. Hospice of Palm Beach County commits to provide a minimum of

$250,000 per year earmarked for complex palliative interventions

such as radiation therapy, chemotherapy, high cost medications,

blood transfusions, and intravenous nutrition. Compliance with

this condition will be documented by an annual affirmative


3. Hospice of Palm Beach County commits to provide two full-time

salaried positions, with bilingual requirement (Spanish and

Creole). Team members will be responsible for the development,

implementation, coordination and evaluation of programs to

increase community knowledge and access to the hospice services.

Compliance will be documented by annual submission of seminars

and programs that were offered and a declaratory statement to the

Agency.

4. Hospice of Palm Beach County commits to recruit bilingual

volunteers. Patients‟ demographic information, including other

languages spoken, is collected so that the most compatible

volunteer can be assigned to fill each patient‟s visiting request.

During the past six months, a targeted bilingual recruiting

program in Palm Beach County resulted in 38 new volunteers

fluent in English and Spanish or Creole. Compliance will be

documented by annual submission of a records summary to the

Agency.

5. Hospice of Palm Beach County commits to establishing a new Vigil

Volunteer Program equipped with a team of specifically trained

volunteers available to respond on short notice to provide presence

during the last few hours of life to patients without family support

or patients and families who need additional support. Vigil

volunteers also provided support to family members who need a

break from the bedside of their loved ones during the dying


109

process. Compliance will be documented by submission of records

summary kept by the Hospice of Palm Beach County volunteer

coordinator to the Agency.

6. Hospice of Palm Beach County commits to offer a separate

children‟s camp to the Broward Community. Camp SeaStar,

Hospice of Palm Beach County‟s annual three-day, two-night camp

for bereaved children is a unique and special opportunity for

volunteers. These retreats provide enhancement to traditional

bereavement services, especially for those children experiencing

problematic grief. Compliance will be documented by annual

submission of camp dates to the Agency.

7. Hospice of Palm Beach County commits to provide bereavement

services beyond the 13 months required by law. Hospice of Palm

Beach County will not limit these services to the families of the

deceased and will offer bereavement counseling to the community-

at-large. Hospice of Palm Beach County will also establish grief

support programs to workplaces that have experienced traumatic

or multiple losses. Compliance will be documented by submission

of bereavement programs that were offered and a declaratory


8. Hospice of Palm Beach County commits to provide music therapy,

massage, aromatherapy, craniosacral therapy, relaxation training,

and Reiki beyond the Medicaid benefit. These measures will

enhance the physical, emotional, and spiritual wellbeing of Hospice

of Palm Beach County‟s patients and families. Compliance will be

documented by an annual declaratory statement to the Agency.

9. Hospice of Palm Beach County commits to expand Joint

Commission accreditation into Broward County upon eligibility to

do so. Compliance will be documented by an annual declaratory


10. Hospice of Palm Beach County commits to provide all services

required by state and federal law and regulations.

Deny CON Numbers 10083, 10084 and 10086.


110

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

Documents

STATE AGENCY ACTION REPORTahca.myflorida.com/MCHQ/CON_FA/Batching/pdf/10085.pdf · and/or the possible creation of an inpatient unit. These include Michael Bokor, CEO of Southern