STATE AGENCY ACTION REPORT
ON APPLICATION FOR CERTIFICATE OF NEED
A.
PROJECT IDENTIFICATION
1.
Applicant/CON Action Number
Palm Court NH, LLC, d/b/a Wilton Manors Health and Rehabilitation
Center/CON #10056
3922 Coconut Palm Drive, Suite 102
Tampa, Florida 33619
Authorized Representative:
2.
William (Bill) Mando
Vice President & CFO
Greystone Healthcare Management
(813) 675-2319
Service District/Subdistrict
District 10 (Broward County)
B.
PUBLIC HEARING
No public hearing was held or requested on the proposed project to add
29 community nursing home beds at 118-bed community skilled nursing
facility (SNF) Wilton Manors Health and Rehabilitation Center (Wilton
Manors) through the delicensure of the 29 inactive beds at Mercy Manor
North.
Letters of Support
The applicant submitted 11 support letters. Project Summary, page #vi,
Exhibit PS-1 includes letters from: John C. Johnson, President and CEO,
Holy Cross Hospital; Shawn Erisman, Director of Case Management,
Kindred Hospital-Fort Lauderdale; Joan Martin, MSW, North Broward
Hospital District and Dr. Rajendra Gupta, Medical Director, Wilton
Manors Health & Rehabilitation Center (Wilton Manors). All four letters
were signed with an April 9, 2009 or more recent date. Mr. Johnson
reported he is an officer of Holy Cross Long Term Care, Inc., the licensee
of Mercy Manor North and that his facility is in full agreement and
cooperation with the project and will voluntarily surrender the applicable
CON Action Number: 10056
license, if the project is approved. Agency for Health Care Administration
licensure records confirm Holy Cross Long Term Care, Inc. holds the
Inactive license for the 29-bed Mercy Manor North facility. Mr. Erisman
indicated his facility works closely with and has had many positive
discharge experiences with Wilton Manors, regarding the placement of
higher acuity patients that require complex care. Ms. Martin of North
Broward reiterated similar comments. Dr. Gupta of Wilton Manors
reported she works closely with Greystone Healthcare Management
leadership in the promotion of positive outcomes for residents, family
members and staff.
The seven support letters found under Volume 2/Tab 10 (Additional
Information) were all signed with a June 4, 2009 date. Four of the seven
letters had North Broward letterhead and three had Wilton Manors
letterhead. All seven of these letters were of a form letter variety, very
similar to the one from Ms. Martin of North Broward.
C.
PROJECT SUMMARY
Palm Court NH, LLC d/b/a Wilton Manors Health and Rehabilitation
Center (CON #10056) proposes to add 29 community nursing home
beds at the 118-bed community skilled nursing facility, Wilton Manors
Health and Rehabilitation Center through the delicensure of the 29
inactive beds at 29-bed Mercy Manor North, Broward County, Florida.
The project will result in no change in the number of community nursing
beds in the district or subdistrict.
Palm Court NH, LLC d/b/a Wilton Manors Health and Rehabilitation
Center is affiliated with Greystone Tribeca Acquisition, LLC, NH Florida
Realty, LLC and Greystone Healthcare Management Corporation. The
applicant indicates that these companies own 14 SNFs with 1,779 beds
and four assisted living facilities (ALFs) with 335 units in Florida; and
operate another nine facilities in two other states.
According to the applicant the two facilities are reportedly approximately
four miles apart. The 29-bed addition is to be connected to Wilton
Manors by a corridor and the site of the 29-bed addition is to replace the
existing Hidden Palms, a 40-bed (30-unit) ALF that is adjacent to Wilton
Manors.
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CON Action Number: 10056
The ALF is set to be delicensed to make way for the 29-bed addition (25
private patient rooms and two semi-private patient rooms). The
applicant contends that there are only 17 community nursing home beds
for every 1,000 residents aged 65 and over within Broward County,
compared to an average of 25 beds per 1,000 elderly residents statewide.
Therefore, the applicant concludes the project will preserve all currently
licensed beds to make the best use of a limited resource and not reduce
access by the loss of 29 licensed beds. Greystone Healthcare
Management Corporation is also stated to be implementing improved
quality improvement mechanisms to raise quality standards and
outcomes, through this project.
The project involves 19,821 total gross square feet (GSF) with 230 GSF of
new construction and 19,591 GSF of renovation. Total construction cost
is $1,149,730. The total cost of the project is $1,917,885. Total project
costs include: land; building and equipment; project development and
start-up.
The applicant proposes no conditions to this project. The facilities do not
presently have any conditions.
D.
REVIEW PROCEDURE
The evaluation process is structured by the certificate of need review
criteria found in Section 408.035, Florida Statutes. These criteria form
the basis for the goals of the review process. The goals represent
desirable outcomes to be attained by successful applicants who
demonstrate an overall compliance with the criteria. Analysis of an
applicant's capability to undertake the proposed project successfully is
conducted by assessing the responses provided in the application, and
independent information gathered by the reviewer.
Applications are analyzed to identify strengths and weaknesses in each
proposal. If more than one application is submitted for the same type of
project in the same district (subdistrict), applications are comparatively
reviewed to determine which applicant best meets the review criteria.
Section 59C-1.010(3)(b), Florida Administrative Code, allows no
application amendment information subsequent to the application being
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.
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CON Action Number: 10056
As part of the fact-finding, the consultant, Steve Love, analyzed the
application in its entirety with consultation from the Financial Analyst,
Derron Hillman, who evaluated the financial data and the Architect,
Scott Waltz, who evaluated the architecturals and the schematic
drawings as part of the application.
E.
CONFORMITY OF PROJECT WITH REVIEW CRITERIA
The following indicate the level of conformity of the proposed project with
the criteria and application content requirements found in Florida
Statutes, Sections 408.035, and 408.037; applicable rules of the State of
Florida, Chapter 59C-1 and 59C-2 and Florida Administrative Code.
1.
Fixed Need Pool
a.
Does the project proposed respond to need as published by a fixed
need pool? Or does the project proposed seek beds or services in
excess of the fixed need pool? Rule 59C-1.008(2), Florida
Administrative Code.
Pursuant to Florida Statutes 408.0435(1), the Florida Legislature
extended a moratorium until July 1, 2011 on the issuance of any
certificate of need (CON) for increases in the number of community
nursing home beds around the state. Due to the moratorium, a fixed
need pool was not published by the Agency and the number of
community nursing home beds will remain constant statewide. This
project, if approved, will not change the bed count in the planning area.
b.
If no Agency policy exists, the applicant will be responsible for
demonstrating need through a needs assessment methodology,
which must include, at a minimum, consideration of the following
topics, except where they are inconsistent with the applicable
statutory or rule criteria:
Population demographics and dynamics;
Availability, utilization and quality of like services in the district,
subdistrict or both;
Medical treatment trends; and
Market conditions.
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CON Action Number: 10056
Population demographics and dynamics
There are 33 community nursing homes in District 10, Broward County,
with a total of 4,229 community nursing home beds1. District 10
(Broward County) averaged 83.06 percent occupancy for the 12-month
period ending December 31, 2008. Broward County is the only county in
the district.
The table below illustrates the annual utilization for the SNF planning to
delicense the 29 inactive beds (Mercy Manor) and the SNF planning to
correspondingly license the 29 beds (Wilton Manors), in the same district
and subdistrict:
Annual Utilization Total
Palm Court NH, LLC d/b/a Wilton Manors Nursing and Rehabilitation Center
District 10 (Broward County)
January 2008-December 2008
Facility
Mercy Manor*
Wilton Manors
District 10
Bed Days
10,614
43,188
1,547,814
Patient
Days
0
39,445
1,285,682
Total
Occup.
0.00%
91.33%
83.06%
Medicaid
Days
0
27,979
814,756
Medicaid
Occup.
0.00%
70.93%
63.37%
Source: Agency for Health Care Administration publication Florida Nursing Home Utilization by
District and Subdistrict January 2008-December 2008, issued April 3, 2009.
* Mercy Manor’s 29 beds have been inactive since August 2, 2007.
For the 12-month period ending December 31, 2008, Wilton Manor’s
averaged 91.33 percent occupancy. Wilton Manors is approximately 4.19
driving miles2 to the southwest of Mercy Manor. The project would
increase the community nursing home beds at Wilton Manors from 118
to 147 and zero out the number of beds at Mercy Manor.
Below is a map showing the location of both Wilton Manors and Mercy
Manors location. The facilities are approximately four miles apart.
Florida Nursing Home Utilization by District and Subdistrict, January 2008 – December 2008, published
April 3, 2009.
2 www.Mapquest.com.
1
5
CON Action Number: 10056
Microsoft MapPoint
The Agency for Health Care Administration published population
projections for District 10, Broward County, indicating the following:
Population Growth
January 2010 to January 2015
District 10 (Broward County)
Population Age Ranges
Broward County
Statewide Total
January 2010
Population
65+
75+
260,410
136,790
3,352,359 1,692,137
January 2015
Population
65+
75+
293,628
138,260
3,943,962
1,850,034
Five-Year Growth
65+
75+
12.76%
1.07%
17.65%
9.33%
Source: Agency for Health Care Administration Population Estimates, published September 2008.
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CON Action Number: 10056
The above table indicates by January 2015, Broward County’s (District
10’s) 65 years of age and older population is expected to grow at a rate of
12.76 percent but at a slower rate than the state overall rate of 17.65
percent. Broward County’s 75 years of age and older population is
expected to also experience growth (at a rate of 1.07 percent) but again at
a slower rate than the state overall (at a rate of 9.33 percent).
The applicant cites Broward County’s total population of 1,775,101 as of
July 1, 20083 and that District 10 (Broward County) is the most densely
populated health planning district in the state4. The applicant further
states that Wilton Manors is centrally located within the district and is
within a 20-minute drive time for 1,186,428 (or about 66 percent) of the
district’s population, using Claritas data (Figure 1-3, 2008 Total
Population by Zip Code, Need Analysis, page #1-7). The applicant
emphasizes that this maximizes access for the 29 beds that, without the
project, would be lost under the moratorium.
The applicant indicates that by 2013, the Broward County age 65 and
over population will rise to 283,709 residents and its 75 and over
population will rise to 138,121 residents. As shown previously,
populations for these age cohorts are expected to continue to rise at least
through January 2015. The applicant estimates that with an increase in
the county’s 65+ population, demand for skilled nursing services will
continue.
Availability, utilization and quality of like services
Concerning availability, there are 33 community nursing homes in
District 10, Broward County, with a total of 4,229 community nursing
home beds5. The applicant points out these figures exclude the
Alexander Nininger State Veterans’ Nursing Home, the Children’s
Comprehensive Care Center and sheltered beds. The applicant stresses
that in 2008, Broward County realized a ratio of only 17 community
nursing home beds per 1,000 residents and this ratio is expected to
decline to 15 per 1,000 residents by 2013. It has been shown that the
elderly population is not expected to decline in the area at least through
Agency for Health Care Administration Population Estimates, published September 2008
Broward County consists of 1,209 square miles and with a population of 1,782,573 is the second
most densely populated county in Florida and the most densely populated health planning district,
with 1,474.54 persons per square mile as of January 1, 2009 per Agency for Health Care
Administration “Population Density in Florida Counties” found in Hospital Bed Need Projections for the
January 2009 Batching Cycle.
5 Florida Nursing Home Utilization by District and Subdistrict, January 2008 – December 2008, published
April 3, 2009
3
4
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CON Action Number: 10056
2015. The applicant again emphasizes the importance of every available
bed remaining licensed to meet continued demand and that this project
will contribute to satisfying that need.
Concerning utilization, the district experienced a total nursing home bed
occupancy rate of 83.06 percent for the 12-month period ending
December 31, 2008. The applicant projects that if nursing home patient
days grow at the same rate as the elderly population, the projected
nursing home bed occupancy rate would rise to 92.41 percent, within
five years which is also year three of the project Wilton Manors
experienced a 91.33 percent occupancy rate for the 12 months ending
December 31, 2008 compared to a district-wide average of 83.06 percent
for the same period. Project approval would enhance availability at one
of the more occupied facilities in the area.
Concerning quality of like services, the applicant states that in some
instances, the Agency’s current scoring mechanism for quality
assessment does not accurately measure the actual quality of services.
The applicant supports this conclusion by showing that in the May 2009
update to the Agency’s Nursing Home Guide, the Agency issued an
overall two of a possible five stars to affiliate SNF Lexington Health and
Rehabilitation Center (in Pinellas County) when the facility realized five of
a possible five stars in all five of the inspection components used to
realize an overall rating, with those five components as follows: nutrition
and hydration; restraints and abuse; pressure ulcers; decline and
dignity. The applicant reports that Greystone Healthcare Management
Corporation is in the process of making renovations and improvements
at some of its existing facilities around the state and that if approved, the
project is set to realize similar quality improvements. The applicant
states that Wilton Manors already accepts higher acuity patients and
that three of its especially higher level services include dialysis, HIV and
tracheotomy care. Support letters indicate that Wilton Manors is
recognized as a source of placement for higher acuity patients. The
applicant states that Wilton Manor’s 24-hour registered nurse (RN)
coverage is an indicator of the high quality of care provided by the
facility. Wilton Manor’s plan to provide 25 of the 29 beds in private
rooms that will be designed to be handicap accessible with showers in
each bathroom are cited as support for its contention that the project will
enhance quality care.
Medical treatment trends
The applicant states that as hospital-based skilled nursing units began
to close following changes in Medicare reimbursement, demand
increased for freestanding nursing facilities with beds being used for
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CON Action Number: 10056
short-term rehabilitation and convalescent days. The project is set to
accommodate this trend by creating a rehabilitation unit in the renovated
space and accept more short-term rehabilitative patients while not
sacrificing its existing ability to absorb higher acuity patient placements.
The applicant contends that the Long-Term Care Community Diversion
Program has also impacted care in Broward County and projects
continued downward pressure on Medicaid occupancy rates in Broward
County and statewide in spite of a rise in Medicaid occupancy rates over
the period (from 60.31 percent in 2001 to 63.37 percent in 2008). For
CY 2004 through 2008, the applicant shows that Wilton Manors had a
higher Medicaid occupancy rate than the district or the state for each of
the four years. It is reiterated that the applicant does not propose any
conditions pursuant to project award. The applicant believes the
proposed 29-bed addition to Wilton Manors will allow the facility to
continue serving the same number of Medicaid eligible residents while
increasing service to short-term rehabilitative residents.
Market conditions
The applicant believes its project will better enable it to compete for the
trending demand of higher acuity and short-term rehabilitative patients.
Palm Court NH, LLC shows that from 2004 through 2008, Wilton Manors
realized annualized total occupancy rates consistently exceeding the
average of those for the district. The applicant shows that in this fiveyear period, its lowest occupancy rate (85.69 percent in 2006) still
exceeded the district’s highest average occupancy (83.95 percent in
2007). Wilton Manors also states that five hospitals are within
approximately five miles of its facility. The cumulative total facility bed
count for the five listed hospitals (Broward General Medical Center,
Florida Medical Center, Holy Cross Hospital, Imperial Point Medical
Center and Plantation General Hospital) is 2,214 beds, with 1,843 being
acute care beds. The Agency notes that none of these five hospitals are
licensed to operate skilled nursing units. The space planned for this
project will absorb existing ALF services which the applicant indicates
are currently well provided within the district as compared to the state
overall. The applicant believes operating efficiencies will be enhanced
through the project by placing into service currently inactive licensed
community nursing home beds at a facility with a history of higher acuity
patient placements. The applicant indicates there is availability at
nearby ALFs within similar price ranges so that ALF residents that will
be impacted by the project may be placed.
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CON Action Number: 10056
2.
Agency Rule Preferences
Does the project respond to preferences stated in Agency rules?
Please indicate how each applicable preference for the type of
service proposed is met. Chapter 59C-1.036, Florida Administrative
Code.
Chapter 59C-1.036 of the Florida Administrative Code does not contain
preferences relative to community nursing home beds nor does the
Agency for Health Care Administration publish specific preferences for
these facilities. However, the rule does contain standards the Agency
utilizes in assessing the applicant’s ability to provide quality care to the
residents.
a.
Geographically Underserved Areas. In a competetitive
certificate of need review within the nursing home subdistrict
as defined in 59C-2.200, Florida Administrative Code, the
Agency shall award a certificate of need if the applicant meets
all applicable criteria for a geographically undeserved area as
specified in subsection 408.032(18), Florida Statutes (Florida
Statutes), and if the applicant meets the applicable statutory
certificate of need review criteria specified in section 408.035,
Florida Statutes, including bed need according to the relevant
bed need formula contained in this rule. If the applicant is
awarded a certificate of need based on the provisions of this
paragraph, the applicant shall agree that the nursing facility
will be located in a county without a nursing facility, or in the
center of an area within the subdistrict of a radius of at least
20 miles which meets the definition of a geographically
undeserved area. The center of the geographically undeserved
area shall be the proposed nursing home location in the
application.
The application is not submitted in order to remedy a
geographically underserved area as described by rule and statutes.
b.
Proposed Services. Applicants proposing the establishment of
Medicare-certified nursing facility beds to be licensed under
Chapter 400, Florida Statutes, shall provide a detailed
description of the services to be provided, staffing pattern,
patient characteristics, expected average length of stay,
ancillary services, patient assessment tools, admission
policies, and discharged policies.
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CON Action Number: 10056
Wilton Manors is stated to participate in both the Medicare and
Medicaid Programs and the 29-bed addition will be certified to
accept such residents as needed. The applicant indicates the new
29-bed unit will be geared toward short-term rehabilitative patients
whose primary payer is Medicare. The applicant includes a list of
25 services it already provides to its current SNF residents and a
brochure to describe its services is included in an attached
brochure (Wilton Manors Health & Rehabilitation Center –
Restoring Health/Enhancing Life). An additional seven amenities
are also shown in the application. The applicant indicates that a
preliminary plan of care is developed with 24 hours of admission
and that the care plan is developed within seven days of
completion of a comprehensive assessment in accordance with the
minimum data set (MDS). An interdisciplinary team is composed
of a list of 11 health care and allied-health practitioners and staff.
Resident and family members are reportedly encouraged to
participate in the health care planning process. According to the
applicant, the care plan is reviewed at least quarterly and other
assessment tools are utilized. Goals and objectives are stated to
lead to the highest possible level of independence.
Outpatient rehabilitation is also stated as available to those who
require it. The applicant’s Agency Rule Conformity, page #2-8,
Exhibit 2-1, Policies and Procedures for Care Planning,
Admissions, Transfers and Discharges, describes the facility’s
admission, readmission, transfer, discharge and related activities.
An in-depth “Resident Rights Materials” protocol is found in the
applicant’s Agency Rule Conformity, page #2-9, Exhibit 2-2.
The applicant states the 29-bed addition will primarily be used as
a Medicare rehabilitation unit. The applicant estimates an
incremental 261 admissions in year one (ending September 30,
2011) and 303 admissions in year two (ending September 30,
2012), with an incremental 9,055 patients days in year one and
9,882 patient days in year two. The applicant proposes an
additional 39.4 FTEs from year one to year two to the existing staff
compliment, with a staffing pattern as illustrated in the table
immediately below.
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CON Action Number: 10056
Palm Court NH, LLC, d/b/a
Wilton Manors Health and Rehabilitation Center - CON #10056
Staffing Patterns
Year One and Year Two of Operation
Position
Administration
Administrator
Director of Nursing
Admissions Clerk
Bookkeeper
Secretary
Medical Records Clerk
TOTAL
PHYSICIANS
Medical Director
TOTAL
NURSING
RN’s
LPN’s
Nurses Aides
Other (Nursing Admin – Indirect)
TOTAL
ANCILLARY
Physical Therapist and PTA
Speech Therapist
Occupational Therapist and OTA
Rehab Manager
Other
TOTAL
DIETARY
Dietary Supervisor
Cooks
Dietary Aides
TOTAL
SOCIAL SERVICES
Social Worker Director
Activities Director
Activities Assistant
Other: Social Services Assistant
TOTAL
HOUSEKEEPING
Housekeeping Supervisor
Housekeepers
TOTAL
LAUNDRY
Laundry Supervisor
Laundry Aides
TOTAL
PLANT MAINTENANCE
Maintenance Supervisor
Maintenance Assistance
TOTAL
GRAND TOTAL
Year One FTEs
Year One Ending
09/30/2011
Year Two FTEs
Year Two Ending
09/30/2012
1.0
1.0
2.0
2.0
2.0
1.0
9.0
1.0
1.0
2.0
2.0
2.0
1.0
9.0
2.0
2.0
2.0
2.0
7.5
18.0
57.5
10.0
93.0
9.5
22.0
71.5
11.5
114.5
5.5
1.5
3.0
1.0
3.0
11.0
12.7
2.5
6.8
1.0
3.0
23.0
1.0
4.0
7.0
12.0
1.0
5.0
8.5
14.5
1.0
1.0
0.5
0.5
3.0
1.0
1.0
1.0
1.0
4.0
1.0
8.0
9.0
1.0
9.7
10.7
1.0
3.0
4.0
1.0
3.7
4.7
1.0
1.0
2.0
145.0
1.0
1.0
2.0
184.4
Source: CON Application #10056 Financial Schedule 6A.
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CON Action Number: 10056
The incremental 39.4 FTE increase over the existing staff
compliment is accounted for through the following additional FTEs:
2.0 registered nurses (RNs); 4.0 licensed practical nurses (LPNs);
14.0 nurses aides; 1.5 nursing administration-indirect; 7.2
physical therapists and PTAs; 1.0 speech therapists; 3.8
occupational therapists and OTAs; 1.0 cooks; 1.5 dietary aides; 0.5
activities assistants; 0.5 social services assistants; 1.7
housekeepers and 0.7 laundry aides. All other staff do not change
from the existing Wilton Manors staff.
Chapter 400.23, Florida Statutes, currently requires a minimum
licensed nursing staffing of 1.0 hours of direct care for each
resident per day and a minimum certified nursing assistant
staffing of 2.9 hours of direct care for each resident per day. The
calculations below are based on the applicant’s proposed staffing
from Schedule 6A and projected occupancy from Schedule 5 of the
application.
Palm Court NH, LLC, d/b/a
Wilton Manors Health and Rehabilitation Center - CON #10056
Minimum Staffing Requirements
FTE
Nurses/Aides
Nurses
Aides
Minimum
Requirement
1.0 hours of direct
care per resident
2.9 hours of direct
care per resident
1st Year
2011
2nd Year
2012
1.31
1.29
2.98
2.92
Sources: Extracted from Schedule 5 & 6 of CON Application #10056.
As shown in the above table, the applicant’s projected staffing
patterns satisfy the minimum requirements outlined in Section
400.23 (3)(a), Florida Statutes for nurses and for nurses’ aides.
c.
Quality of Care. In assessing the applicant’s ability to provide
quality of care pursuant to s. 408.035(1), Florida Statutes, the
Agency shall evaluate the following facts and circumstances:
1.
Whether the applicant has had a Chapter 400, Florida
Statutes, nursing facility license denied, revoked, or
suspended within the 36 months prior to the
application.
The applicant states it has not had a nursing home license
denied, revoked, or suspended.
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CON Action Number: 10056
2.
Whether the applicant has had a nursing facility placed
into receivership at any time during the period of
ownership, management, or leasing of a nursing facility
in the 36 months prior to the current application.
The applicant states it has not had a nursing facility placed
into receivership at any time.
3.
The extent to which the conditions identified within
subparagraphs 1 and 2 threatened or resulted in direct,
significant harm to the health, safety, or welfare of the
nursing facility residents.
The applicant states that since there have been no violations
this provision is not applicable.
4.
The extent to which the conditions identified within
subparagraph 3 were corrected within the time frames
allowed by the appropriate state agency in each
respective state and in a manner satisfactory to the
agency.
The applicant states that since there have been no violations
this provision is not applicable.
(4) (f) Harmful Conditions. The Agency shall question the ability of
the applicant to provide quality of care within any nursing facility
when the conditions identified in subparagraph (e) 1 and (e) 2 result
in the direct, significant harm to the health, safety, or welfare of a
nursing facility resident, and were not corrected within the time
frames allowed by the appropriate state agency in each respective
state and in a manner satisfactory with the Agency.
The applicant states that since there have been no violations, this
provision is not applicable. Refer to quality of care discussion below in
section E.3.b. of this report.
(5) Utilization Reports. Within 45 days after the end of each
calendar quarter, facilities with nursing facility beds licensed under
Chapter 400, Florida Statutes shall report to the Agency, or its
designee, the total number of patient days, which occurred in each
month of the quarter, and the number of such days that were
Medicaid patient days.
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CON Action Number: 10056
The applicant states it will continue to provide the required data to the
Broward Regional Health Planning Council, Inc. and to the Agency.
3.
Statutory Review Criteria
a.
Is need for the project evidenced by the availability, quality of care,
efficiency, accessibility and extent of utilization of existing health
care facilities and health services in the applicant's service area?
ss. 408.035 (1)(b) and (e), Florida Statutes.
As stated previously, there are 33 community nursing homes in District
10, Broward County, with a total of 4,229 community nursing home
beds6. District 10 averaged 83.06 percent occupancy for the 12-month
period ending December 31, 2008. The applicant reports that the bed
supply has held relatively constant since 2001 to 2008 and will either
remain constant or possibly decrease under the moratorium. With a
growing elderly population, the applicant contends that additional
demand will be placed on the bed supply. The applicant’s major
contention is that preservation of nursing home beds ensures continued
availability, where there is a moratorium and a growing elderly
population environment.
Per the applicant, though the facility (Wilton Manors) has historically
performed low on survey results Greystone has developed and
implemented quality assurance improvements. A particular quality
consideration the applicant denotes is that the project will create 25
private and two semi-private rooms at Wilton Manors and that this will
lead to better rehabilitation and complex care for patients. The applicant
indicates renovations of the entire facility will meet or exceed all
minimum size requirements and modernize the unit with all handicap
accessible bathrooms with showers in each patient room. See section
E.3.f regarding handicap accessible toilets and showers in each patient
room.
Regarding geographic access, the applicant reports that considering that
District 10 (Broward County) is the most densely populated health
planning district in the state, location is not a factor in access. The
greater issue, per the applicant, is to preserve the number of community
nursing home beds in the district, which is the project’s objective. The
project will delicense 29 inactive community nursing home beds and
relicense them approximately four miles toward the southwest of
Florida Nursing Home Utilization by District and Subdistrict, January 2008 – December 2008, published
April 3, 2009
6
15
CON Action Number: 10056
Broward County, more centrally locating the beds within the district.
The applicant reports that Wilton Manors participates in both the
Medicare and Medicaid programs and will continue to do so with this
project. It is stated the project will primarily be used as a rehabilitation
unit. The new unit that will accommodate the 29 beds from Mercy
Manor North will increase the proportion of Medicare, while the payer
mix at the remaining and currently licensed 118-bed Wilton Manors will
maintain approximately the same payer mix. Regarding utilization, the
applicant points out that Wilton Manors has consistently been highly
utilized and the project will serve to provide additional capacity at a
highly utilized facility without adding bed supply to the district overall.
The applicant elects to respond to additional criteria - the Health Care
Access Criteria, as stated in Chapter 59C-1.030(2). Below are the
applicant’s volunteered responses.
(a)
The need that the population served or to be served has for
the health or hospice services proposed to be offered or
changed, and the extent to which all residents of the district,
and in particular low income persons, racial and ethnic
minorities, women, handicapped persons, other underserved
groups and the elderly are likely to have access to those
services.
The applicant projects 50,116 total patient days in year one and
51,240 total patient days in year two. In year one, the Medicaid
patient days are projected at 26,678 and the Medicare and
Medicare HMO patient days are projected at 20,153. In year two,
the Medicaid patient days are projected at 26,563 and the
Medicare and Medicare HMO patient days are projected at 21,383.
This reflects a decline of 115 Medicaid patient days from year one
to year two and an increase of 1,230 Medicare and Medicare HMO
patient days for the same period. Per the applicant’s Schedule 7,
for the entire 147-bed proposed Wilton Manors for year one, the
anticipated Medicaid percent of patient days is 53.2 and for year
two, the anticipated Medicaid percent of patient days is 51.8. Both
the 53.2 percent and 51.8 percent estimate are below the average
Medicaid patient day percentage district-wide of 63.37 percent for
the 12-month period ending December 31, 2008. However, the
project is designed to accommodate short-term rehabilitation and
complex care patients with Medicare as the primary payer.
16
CON Action Number: 10056
(b)
The extent to which that need will be met adequately under a
proposed reduction, elimination or relocation of a service,
under a proposed substantial change in admissions policies or
practices, or by alternative arrangements, and the effect of the
proposed change on the ability of members of medically
underserved groups which have traditionally experienced
difficulties in obtaining equal access to health services to
obtain needed health care.
The applicant anticipates any change in geographic access will be
minimal (driving distance between Mercy Manor North and Wilton
Manors is approximately 4.10 miles). The applicant states that
Wilton Manors will realize 25 more private rooms (with two semiprivate rooms) and that the private rooms will benefit those with
complex needs as well as those requiring rehabilitation. The
applicant states that the opportunity to transfer beds currently
inactive improves access for the community, with additional
private skilled nursing beds at a facility that is already
experiencing high demand.
(c)
The contribution of the proposed service in meeting the health
needs of members of such medically underserved groups,
particularly those needs identified in the applicable local
health plan and state health plan as deserving of priority.
Wilton Manors states this is not applicable, as local health plans
are no longer published.
(d)
In determining the extent to which a proposed service will be
accessible, the following will be considered:
1.
The extent to which medically underserved individuals
currently use the applicant’s services, as a proportion of
the medically underserved population in the applicant’s
proposed service area(s), and the extent to which
medically underserved individuals are expected to use
the proposed services, if approved;
Wilton Manors provides a table to describe its contribution to
reaching out to the medically underserved. For the 12month period ending December 31, 2008, Medicaid patient
days were 70.93 percent of Wilton Manors’ occupancy
compared to the District 10 average of 63.37 percent. The
applicant has consistently shown a commitment to the
medically underserved and regularly reported higher
Medicaid percentages than the district overall. However, this
17
CON Action Number: 10056
project is designed to be a rehabilitation and complex care
patient unit, with appreciably no Medicaid reimbursement to
be realized as a result of the 29-bed addition and 100
percent Medicare and Medicare HMO reimbursement for the
added unit.
2.
The performance of the applicant in meeting any
applicable Federal regulations requiring uncompensated
care, extent to which medically underserved individuals
currently use the applicant’s services, as a proportion of
the medically underserved population in the applicant’s
proposed service area(s), and the extent to which
medically underserved individuals are expected to use
the proposed services, if approved;
Wilton Manors reports being active in the Medicare and
Medicaid Programs and adheres to the conditions of
participation, in addition to being in compliance with state
and federal regulatory agencies.
3.
The extent to which Medicare/Medicaid and medically
indigent patients are served by the applicant; and
The applicant provides a table to describe Wilton Manors’
Medicare/Medicaid and self-pay/charity patient estimates
(Conformity with Health Planning Factors, page #3-9, Table
3-3/Patient Days by Payer for Wilton Manors Health &
Rehabilitation Center First Two Years of the 29-Bed
Addition). For the 147-bed facility, Wilton Manors estimates
26,678 Medicaid patient days in year one and 26,563
Medicaid patient days in year two. Wilton Manors states the
majority of the facility’s patient days come from Medicaid
patients. The calculations indicate that Medicaid is the
single greatest funding source at 53.2 percent in year one
and 51.8 percent in year two. Medicare and Medicare HMO
is the second largest payer with 40.2 percent in year one and
41.8 percent in year two.
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CON Action Number: 10056
4.
The extent to which the applicant offers a range of
means by which a person will have access to its services.
Wilton Manors indicates access to services available include:
Medicaid, Medicare, contracts with major health
maintenance organizations; contracts for hospice care; local
and state agency entitlement opportunities and community
outreach programs.
b.
Does the applicant have a history of providing quality of care? Has
the applicant demonstrated the ability to provide quality care? Is
the applicant a Gold Seal Program nursing facility that is proposing
to add beds to an existing nursing home? ss. 408.035 (1)(c) and (j),
Florida Statutes.
As the licensee of Wilton Manors, Palm Court NH, LLC also reports
affiliation with other Florida nursing homes and assisted living facilities,
these are: Greystone Tribeca Acquisition, LLC, NH; Florida Realty, LLC
and Greystone Healthcare Management Corporation. The applicant
states the companies own and operate 14 SNFs with 1,779 beds and four
ALFs with 335 units, throughout Florida. The applicant provides a table
listing its 14 SNF affiliates (Applicant’s Quality of Care, page #4-1, Table
4-1/Florida Affiliated Nursing Homes of Greystone). Of these 14 facilities
for the 12-month period ending December 31, 2008, Wilton Manors is
listed as the only Greystone SNF in District 10, with a total occupancy
rate of 91.33 percent. Again, of the 14 listed SNFs, the least occupied
was Apollo Health and Rehabilitation Center in Pinellas County (at 81.84
percent) and the most occupied was Lady Lake Specialty Care Center in
Lake County (at 96.75 percent). The most recent Agency inspection
rating of Wilton Manors indicates an overall one-star rating (of a five
possible star rating)7. This is as of an internet run date of June 11, 2009
with the Agency’s Nursing Home Guide last updated in May 2009. The
applicant indicates the 14 SNFs have an average occupancy of 90.83
percent (CY 2008) and that this is above the statewide average nursing
home occupancy rate of 87.35 percent for the same period. These
occupancy rates are confirmed by the Agency. The applicant does not
indicate any of its 14 affiliate SNFs are Gold Seal facilities and does not
disclose their Agency quality ratings.
Palm Court NH, LLC provides Agency licensure for Wilton Manors
(Applicant’s Quality of Care, page #4-12, Exhibit 4-1/Facility License and
Certifications). In the same exhibit is found Wilton Manors’ 2009
Agency Nursing Home Guide at
http://ahcaxnet.fdhc.state.fl.us/nhcguide/ViewFacilityData.aspx?Region=10.
7
19
CON Action Number: 10056
certificate of membership in the Florida Health Care Association (FHCA).
A 2009 American Health Care Association membership certificate is also
included but does not name Wilton Manors, any of its affiliates or its
parent as the certificate recipient. Also, an April 2009 Achievement
Award is provided, naming Wilton Manors as the recipient of the 2008
Deficiency Free Life Safety Survey Award, but the issuer is not named.
Wilton Manors states it (along with other Greystone affiliates) has
recently taken advantage of the FHCA Quality Credentialing Program.
The FHCA’s credentialing process includes an internal and external
review process of quality issues, which the applicant discusses
(Applicant’s Quality of Care, pages 4-2 to 4-7).
Wilton Manors includes quality improvement measures in its Quality of
Care, page #4-13, Exhibit 4-2. This includes the BELIEVE Balanced
Assessment tool, the Operation Make a Difference program and the
Clinical Focus Leveling System (the latter being a five level monitoring
protocol). The applicant also provides numerous periodic check-off
materials to document relevant changes and on-going patient activities
and needs (page #4-14, Exhibit 4-3/Quarterly System Review). The
applicant further provides a mechanism to recognize and catalogue
customer concerns and acknowledgements (page #4-15, Exhibit 4-4).
Quality assurance guidelines are provided for Agency review (page #4-16,
Exhibit 4-5,) along with July 2008 resident council meeting minutes, a
sample June 2009 Wilton Manors newsletter and a month long activities
calendar (page #4-17, Exhibit 4-6). These reflect the applicant’s
commitment to quality.
Agency records indicate 19 confirmed and three confirmed without
deficiency complaints at Wilton Manors for the three-year period ending
June 10, 2009. The 19 confirmed complaints were for the following
complaint categories: resident rights (three); call lights, inappropriate
discharge, medical records/charting, pressure sores and resident care
(two each) and falls/injury, lack of assessment, medicine problem/
errors/formulary, nursing service, plan of care and untrained/
unqualified staff (one each). The three confirmed without deficiency
complaints were for the following complaint categories: call lights,
medical records/charting and medicine problem/errors/formulary (one
each).
20
CON Action Number: 10056
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.
The financial impact of the project will include the project cost of
$1,917,885 and incremental year two operating costs of $3,439,440.
An audit of the applicant was not provided as required under Section
408.037(1)(c), Florida Statutes. In a meeting prior to the filing deadline,
the applicant indicated that it could not provide an audit of the applicant
because FIN 46(R) required that the applicant be included in the
consolidated financial statements of its parent company (Greystone
Tribeca Acquisition, LLC). The applicant argues that requiring an audit
of the applicant in this case would result in a disclaimer opinion from the
auditor under Generally Accepted Accounting Principals (GAAP). The
Agency disagrees with this interpretation of FIN 46(R). While the Agency
agrees that FIN 46(R) requires the parent to report all variable interest
entities, including the applicant, as part of its consolidated financial
statements, it does not appear to preclude an audit of the applicant on a
stand-alone basis.
In any event, funding for this project will be provided by the parent
company and audited financial statements of the parent were submitted.
Although the parent audit does not meet the filing requirements for an
audit of the applicant, the Agency was able to evaluate the applicant’s
balance sheet and income statement for 2008 through an analysis of the
consolidating schedules. The Agency could not analyze the applicant’s
2008 cash flow statement since it was not part of the consolidating
schedules. The Agency believes this information substantially meets the
statutory filing requirements and is sufficient to evaluate the applicant’s
and parent’s ability to fund the project.
Audited financial statements for the periods ending December 31, 2007
and 2008, were analyzed for the purpose of evaluating the applicant’s
and parent’s ability to provide the capital and operational funding
necessary to implement the project.
Short-Term Position:
Applicant - The applicant’s current ratio of 5.0 is well above average and
indicates current assets are approximately five times current liabilities, a
strong position. The working capital (current assets less current
liabilities) of $2.1 million is a measure of excess liquidity that could be
used to fund capital projects. The ratio of cash flows to current liabilities
21
CON Action Number: 10056
could not be determined since the 2008 consolidated schedules did not
include a cash flow statement. Overall, the applicant has a good shortterm position. (See Table below).
Parent - The parent’s current ratio of 2.6 is above average and indicates
current assets are approximately two and a half times current liabilities,
a good position. The working capital (current assets less current
liabilities) of $21.5 million is a measure of excess liquidity that could be
used to fund capital projects. The ratio of cash flows to current liabilities
of 0.9 is well above average and indicates that operating cash flows is
sufficient to cover 90 percent of current obligations, a good position.
Overall, the parent has a good short-term position. (See Table below).
Long-Term Position:
Applicant - The ratio of long-term debt to net assets of 0.0 indicates the
applicant has no long-term debt and therefore has excess equity in which
it could use to acquire additional debt if needed, a good position. The
most recent year had $955,086 of revenue in excess of expenses, which
resulted in an operating margin of 9.3 percent. As discussed above,
2008 cash flow information was not available. Overall, the applicant has
a good long-term position. (See Table below).
Parent - The ratio of long-term debt to net assets of -9.5 indicates the
parent has no positive equity to borrow against, a weak position. The
majority of the debt is mortgage debt secured by substantially all of the
personal property of the parent. The ratio of cash flow to assets of 9.7
percent is average and an adequate position. The most recent year had
$9.2 million of revenue in excess of expenses, which resulted in an
operating margin of 5.5 percent. Overall, the parent has a slightly weak
but adequate long-term position. (See Table below).
Capital Requirements:
Schedule 2 listed capital projects totaling $2.2 million including this
project.
Available Capital:
Funding for this project will be provided by the parent company. As
discussed above, the parent has working capital of $21.5 million and
$9.6 million in operating income. In addition, cash flow from operations
was $12.6 million.
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CON Action Number: 10056
Staffing:
Schedule 6A indicates, for both September 30, 2011 and for September
30, 2012 (the first year and second year of the proposed project,
respectively), the applicant forecasts 184.4 FTEs. As stated previously
the project results in an incremental 39.4 FTEs added to the facility’s
existing 145.0 total FTEs.
Conclusion:
Funding for this project and the entire capital budget should be available
as needed.
CON #10056 - December 31, 2008 Audited Financial Statements
Parent
Applicant
Current Assets
$35,361,115
$2,580,532
Cash and Current Investment
$8,663,669
$1,077,945
Assets limited to use
$1,342,093
$0
$130,286,623
$4,414,572
Total Assets
Current Liabilities
$13,858,666
$512,505
Total Liabilities
$144,013,566
$512,505
Net Assets
($13,726,943)
$3,902,067
Total Revenues
$167,260,448
$10,281,682
Interest Expense
$7,296,189
$0
Excess of Revenues Over Expenses
$9,183,597
$955,086
Cash Flow from Operations
$12,626,658
N/A
Working Capital
$21,502,449
$2,068,027
FINANCIAL RATIOS
Parent
Applicant
Current Ratio (CA/CL)
2.6
5.0
Cash Flow to Current Liabilities (CFO/CL)
0.9
N/A
Long-Term Debt to Net Assets (TL-CL/NA)
-9.5
0.0
Times Interest Earned (NPO+Int/Int)
2.3
N/A
-10.5%
88.4%
Operating Margin (ER/TR)
5.5%
9.3%
Return on Assets (ER/TA)
7.0%
21.6%
Operating Cash Flow to Assets (CFO/TA)
9.7%
N/A
Net Assets to Total Assets (TE/TA)
d.
What is the immediate and long-term financial feasibility of the
proposal? ss. 408.035(1)(f), Florida Statutes.
A comparison of the applicant’s estimates to the control group values
provides for an objective evaluation of financial feasibility, (the likelihood
that the services can be provided under the parameters and conditions
contained in Schedules 7 and 8), and efficiency, (the degree of economies
23
CON Action Number: 10056
achievable through the skill and management of the applicant). In
general, projections that approximate the median are the most desirable,
balancing the opposing forces of feasibility and efficiency. In other
words, as estimates approach the highest in the group, it is more likely
that the project is feasible, because fewer economies must be realized to
achieve the desired outcome. Conversely, as estimates approach the
lowest in the group, it is less likely that the project is feasible, because a
much higher level of economies must be realized to achieve the desired
outcome. These relationships hold true for a constant intensity of service
through the relevant range of outcomes. As these relationships go
beyond the relevant range of outcomes, revenues and expenses may
either go beyond what the market will tolerate or may decrease to levels
where activities are no longer sustainable.
Comparative data was derived from skilled nursing facilities that
submitted Medicaid cost reports in fiscal year 2007 and 2008. The
Agency selected 10 similar sized skilled nursing facilities (including the
applicant) with similar Medicaid utilization. Per diem rates are projected
to increase by an average of 3.0 percent per year, through December
2012. The price adjustment factor used was based on the new CMS
Market Basket Price Index as published in the 1st Quarter 2009 Health
Care Cost Review.
Projected net revenue per patient day (NRPD) of $300 in year one and
$312 in year two is between the control group median and highest values
of $288 and $342 in year one and $296 and $352 in year two. With net
revenues between the median and highest values in the control group,
the facility is expected to consume health care resources in proportion to
the services provided. (See Table below). In its 2008 Medicaid cost
report, the applicant reported NRPD of $256. The difference in the NRPD
reported in 2008 and the year two projected NRPD of $312 results in an
average compound annual increase of approximately 5.4 percent. This
level of increase is above the inflation percentage outlined in the CMS
Market Basket, 1st Quarter, 2009, index. It should be noted that the
beds added by this project will be filled with Medicare patients. Medicare
reimbursement rates are typically higher than the average revenue per
patient day. Projected revenues appear to be reasonable.
Anticipated cost per patient day (CPD) of $261 in year one and $265 in
year two is between the control group median and lowest values of $269
and $229 in year one and $276 and $236 in year two. With net revenues
between the median and lowest values in the control group, projected
costs are considered efficient. (See Table below). In its 2008 Medicaid
cost report, the applicant reported CPD of $232. The difference in the
CPD reported in 2008 and the year two projected CPD of $265 results in
24
CON Action Number: 10056
an average compound annual increase of approximately 3.6 percent.
This level of increase is slightly above the inflation percentage outlined in
the CMS Market Basket, 1st Quarter, 2009, index. It should be noted
that the beds added by this project will be filled with Medicare patients.
Medicare patients tend to receive rehab level services which are a higher
cost than the average cost per patient day. Costs appear to be slightly
overstated and therefore reasonable.
Section 400.23(3)(a)(2), Florida Statutes, specifies a minimum certified
nursing assistant staffing of 2.9 hours of direct care per resident per day
and a minimum licensed nursing staffing of 1.0 hour of direct resident
care per resident day. Based on the information provided in Schedule 6,
the applicant’s projected licensed nursing staffing and direct care
exceeds the minimum level required in year one and year two.
The year two operating profit for the skilled nursing facility of $2.4
million computes to an operating margin per patient day of $47 which is
above the control group highest value of $24. This suggests the level of
profitability might be overstated. In 2008, the applicant reported a
healthy operating margin of $24 per patient day or 9.3 percent. This
project is not likely to have a negative impact on the applicant since it is
an expansion of profitable operations.
Conclusion:
This project appears to be financially feasible based on the prior
profitable operations of the facility.
25
CON Action Number: 10056
CON #10056
Sep-12
YEAR 2
VALUES ADJUSTED
SELECT FY 2007/2008
YEAR 2
ACTIVITY
FOR INFLATION
ACTIVITY
PER PAT. DAY
Highest
Median
Lowest
13,354,950
261
300
238
195
3,317,990
65
131
99
55
10,000
0
8
1
-2
16,682,940
326
427
344
258
710,860
14
0
0
0
15,972,080
312
352
296
251
ADMINISTRATIVE
2,965,010
58
113
71
45
ANCILLARY
2,844,420
56
72
43
27
PATIENT CARE
6,806,790
133
156
131
123
PROPERTY
828,310
16
53
27
11
OTHER
123,960
2
13
4
2
13,568,490
265
343
276
236
2,403,590
47
24
11
-2
COST REPORT DATA
ROUTINE SERVICES
ANCILLARY SERVICES
OTHER OPERATING REVENUE
GROSS REVENUE
DEDUCTIONS FROM REVENUE
NET REVENUES
EXPENSES
TOTAL EXPENSES
OPERATING INCOME
15.0%
PATIENT DAYS
51,240
VALUES NOT ADJUSTED
TOTAL BED DAYS AVAILABLE
53,655
FOR INFLATION
TOTAL NUMBER OF BEDS
PERCENT OCCUPANCY
PAYER TYPE
Highest
Median
Lowest
95.50%
95.6%
90.6%
78.2%
PATIENT DAYS
% TOTAL
3,294
6.4%
MEDICAID
26,563
51.8%
69.0%
56.9%
40.6%
MEDICARE
31.6%
22.6%
12.3%
SELF PAY
21,383
41.7%
INSURANCE
0
0.0%
HMO/PPO
0
0.0%
OTHER
0
0.0%
51,240
100.0%
TOTAL
e.
147
Will the proposed project foster competition to promote quality and
cost-effectiveness? ss. 408.035(1)(g), Florida Statutes.
Competition to promote quality and cost-effectiveness is driven primarily
by the best combination of high quality and fair price. Competition
26
CON Action Number: 10056
forces health care facilities to increase quality and reduce charges/costs
in order to remain viable in the market. The health care industry has
several factors that limit the impact competition has on promoting
quality and cost effectiveness. These factors include a “disconnect”
between the payer and the end user of health care services, and a lack of
consumer friendly quality measures and information. These factors
make it difficult to measure the impact this project will have on
competition to promote quality and cost-effectiveness. However, the
Agency can measure the potential for competition to exist in a couple of
areas.
Provider-Based Competition:
This application is for a transfer of 29 skilled nursing facility beds in
District 10 (Broward County). Considering this project is not adding
beds to the district/subdistrict and the bed transfer is relatively small,
this project is not likely to have a material impact on provider-based
competition.
Price-Based Competition:
The impact of the price of services on consumer choice is limited to the
payer type. The impact of price-based competition would be limited to
payers that negotiate price for services, namely managed care
organizations, commercial insurers and increasingly individual health
care consumers. Therefore, price competition is limited to the share of
patient days that are under managed care plans and self-pay patients.
The applicant is projecting 29.5 percent of its patient days from nonfixed price government payers. Therefore, the potential for price-based
competition exists among 29.5 percent of the applicant’s projected
patient days.
Conclusion:
This project is not likely to have a material impact on provider-based
competition; however, the potential for price-based competition exists for
29.5 percent of the applicant’s projected patient days.
f.
Are the proposed costs and methods of construction reasonable? Do
they comply with statutory and rule requirements? ss.
408.035(1)(h), Florida Statutes; Ch. 59A-4, Florida Administrative
Code.
The applicant proposes to add 29 skilled nursing beds to Wilton Manors
in District 10 (Broward County). The 29 new beds established at the
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CON Action Number: 10056
facility will be gained through the delicensure of an equal number of beds
from Mercy Manor North (within the same district). The new beds would
be located in a portion of Wilton Manors that is currently an ALF named
Hidden Palms which would be closed and renovated as a SNF.
The construction type is not listed on the schematic floor plans or in the
construction section of the application. The building materials are not
described in the submission and there is no reference to existing or new
fire resistant construction other than the possible addition of a four-hour
wall. The unit where the 29 beds are to be added is currently licensed as
an ALF. ALFs are classified as Occupancy Group R-4. As an R-4
occupancy, the permitted construction types and allowable building
areas are less restrictive than that of a nursing home (Occupancy Group
I-2). It may be necessary to upgrade the construction type to bring the
facility in to compliance with current codes. A new wall and a pair of
cross-corridor doors would be installed to sub-divide the facility into
smoke compartments as required by code.
The planned 29 beds will be located in an existing L shaped building
near the existing 118-bed nursing home. The applicant intends to make
renovations necessary to support the additional 29 nursing homes beds
and create a connector to the existing facility for access to additional
required space that are not provided in the new portion of the facility.
These renovations will widen the corridors to comply with current code
requirements and create handicap accessible toilet/shower rooms in
each resident room. Twenty-five of the beds will be located in private
rooms and the other four will be in semi-private rooms. All resident
rooms appear to meet current code requirements.
All required functional space have been provided and are adequately
sized and located. The plan indicates that some required function spaces
are located in the existing nursing home. Plans submitted for
subsequent reviews should show these spaces.
The application does not indicate whether or not the facility currently
meets the disaster preparedness requirement for nursing homes.
Depending on the age of the facility many of these requirements may
have been in place when the facility was built. Compliance with these
requirements will need to be verified as the project is developed.
The project summary on the plan indicates compliance with some of the
more pertinent codes. Additional applicable codes must be listed on
future submissions. Some additional architectural, mechanical and
electrical physical plant standards will need to be addressed in greater
detail as the project is developed, but the physical constraints of the
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CON Action Number: 10056
spaces should accommodate these requirements. The resident rooms are
adequately sized and the facility should be able to meet or exceed all
code requirements. Some additional work may be required to upgrade
the building construction type and to provide impact protection for
exterior units (doors, window and louvers) and other disaster
preparedness requirements.
The estimated construction costs appear to be within the expected range.
These costs may increase if additional work is required to bring the
building into code compliance.
The information provided in the project completion forecast appears to be
reasonable.
The architectural review of the application shall not be construed as an
in-depth effort to determine complete compliance with all applicable
codes and standards. The final responsibility for facility compliance
ultimately rests with the owner.
g.
Does the applicant have a history of and propose the provision of
health services to Medicaid patients and the medically indigent?
ss. 408.035(1)(i), Florida Statutes.
Wilton Manors states intentions to continue to provide the same level of
Medicaid as it has in the past, with the 29-bed addition to be primarily
for rehabilitative care. While the proportionate amount of Medicaid is
expected to go down slightly, actual Medicaid utilization is expected to
remain about the same. The applicant indicates intentions to continue
to care for all patients, regardless of payer source, with project
implementation. The following table compares annual occupancy rates
for Wilton Manors, District 10 and the state, during January 2008
through December 2008.
CY 2008 Patient Days
Percent Total Occupancy & Medicaid
Wilton Manors Health & Rehabilitation Center
District 10
State
Total
91.33%
83.06%
87.35%
Medicaid
70.93%
63.37%
60.69%
Source: Agency for Health Care Administration publication Florida Nursing Home
Utilization by District and Subdistrict January 2008-December 2008, issued April 3, 2009.
The applicant has historically shown a commitment to the medically
underserved but does not commit to condition the project. Wilton
Manors has a consistent pattern of maintaining a higher Medicaid
occupancy than District 10 overall, from 2004 through 2008. Wilton
Manors Health & Rehabilitation Center expects a slight drop in Medicaid
29
CON Action Number: 10056
patient days from year one to year two and a corresponding increase in
Medicare patient days for the same period. This accounts for the 29-bed
addition seeking to accommodate rehabilitation and complex patient care
demand, with Medicare as the primary payer. The applicant states all
beds will be Medicare and Medicaid-certified.
F.
SUMMARY
Palm Court NH, LLC d/b/a Wilton Manors Health and Rehabilitation
Center (CON #10056) proposes to add 29 community nursing home
beds at 118-bed community skilled nursing facility Wilton Manors Health
and Rehabilitation Center through the delicensure of the 29 inactive beds
at 29-bed Mercy Manor North, Broward County, Florida. The project, if
approved, will result in no change in the number of community nursing
beds in the district or subdistrict.
The project involves 19,821 total GSF with 230 GSF of new construction
and 19,591 GSF of renovation. The applicant proposes $1,149,730 in
total construction costs ($1,120,980 for renovation and $28,750 in new
construction). The total cost of the project is $1,917,885. Total project
costs include the following: land; building and equipment; project
development and start-up.
The applicant proposes no conditions to this project. Wilton Manors and
Mercy Manor North do not have CON conditions.
Need:
Need analysis includes evidence that Wilton Manors averaged 91.33
percent in its 118 beds. Wilton Manors exceeded the district’s 83.06
percent average occupancy during the 12-month reporting period,
ending December 31, 2008.
● Using Claritas data, the applicant shows that in 2008, some
1,186,428 residents (or about 66.0 percent) of the entire District 10
population of 1,785,344 residents, are within a 20-minute drive time
radius of Wilton Manors. The project site is both centrally located
geographically in Broward County and located within approximately a
20 minute drive time of 66.0 percent of the district’s population. The
applicant further states that by 2013, the Broward County age 65 and
over population will rise to 283,709 residents and its 75 and over
population will rise to 138,121 residents. This shows continued
growth of the elderly population at least for the next five years. The
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CON Action Number: 10056
applicant concludes some of these residents will likely be in need of
SNF care and the project will better accommodate access, availability
and utilization.
● Agency records indicate total occupancy in the district at 83.06
percent for calendar year 2008, which is lower than the statewide
average occupancy of 87.35 percent. However, Wilton Manors
experienced a relatively high occupancy rate for the same period
(91.33 percent). Wilton Manors was the ninth most occupied of the
33 facilities in the district for the period. Project approval would
better utilize existing licensed beds in the district in that it would
transfer inactive beds at Mercy Manor to a relatively high occupancy
facility.
Quality of Care:
● As of a June 11, 2009 Wilton Manors had one of a possible five-star
quality inspection rating, as issued by the Agency.
● As of the three-year period ending June 10, 2009, Agency records
indicate 19 confirmed and three confirmed without deficiency
complaints at Wilton Manors. The 19 confirmed complaints were for
the following complaint categories: resident rights (three); call lights,
inappropriate discharge, medical records/charting, pressure sores
and resident care (two each) and falls/injury, lack of assessment,
medicine problem/ errors/formulary, nursing service, plan of care
and untrained/ unqualified staff (one each). The three confirmed
without deficiency complaints were for the following complaint
categories: call lights, medical records/charting and medicine
problem/errors/formulary (one each).
Financial Feasibility/Availability of Funds:
● Overall, the applicant and parent have good short-term positions and
the applicant has a good long-term position while the parent has a
slightly weak but adequate long-term position. Funding for the
project and the entire capital budget should be available as needed.
● The project appears to be financially feasible based on the prior
profitable operations of the facility.
● The project is not likely to have a material impact on provider-based
competition; however, the potential for price-based competition exists
for 29.5 percent of the applicant’s projected patient days.
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CON Action Number: 10056
Medicaid/Charity Care:
● Wilton Manors is projecting the proposal will realize 115 fewer
Medicaid patient days in year two than in year one but gain an
estimated 1,230 Medicare and Medicare HMO patient days in year
two. In year one, 53.2 percent of patient days are anticipated to be
dedicated to Medicaid recipients and in year two, 51.8 percent of
patient days are anticipated to be dedicated to Medicaid recipients.
● The applicant has a history of providing care to Medicaid recipients
and the medically indigent, with 70.93 percent Medicaid for 2008.
Broward County averaged 63.37 percent Medicaid occupancy in CY
2008.
● The applicant elects to propose no Medicaid percentage as a
condition.
Architectural:
● The proposed 29 community nursing home bed addition is to be
constructed in renovated space at the current ALF Hidden Palms and
attached by a connector to Wilton Manors. Of the 29 beds, 25 will be
located in private rooms and the remaining four will be in semiprivate rooms. All resident rooms appear to meet current code
requirements and will have handicap accessible toilet/shower rooms.
● The construction type is not provided for Agency review, the building
materials are not described, there is no reference to existing or new
fire resistant construction and the applicant does not indicate
whether or not the facility currently meets disaster preparedness
requirement for nursing homes. The applicant must ensure that
Occupancy Code I-2 is met for a SNF addition, along with disaster
preparedness prerequisites. The applicant proposes $1,149,730 in
total construction costs.
● The estimated construction costs appear to be within the expected
range and the project completion forecast appears to be reasonable.
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CON Action Number: 10056
G.
RECOMMENDATION
Approve CON #10056 to add 29 community nursing home beds at the
118-bed community nursing facility, Wilton Manors Health and
Rehabilitation Center, through the delicensure of the 29 inactive beds at
29-bed Mercy Manor North, Broward County, District 10. The proposed
total project cost is $1,917,885. The project involves 19,821 total GSF
with 230 GSF of new construction and 19,591 GSF of renovation and
$1,149,703 in total construction costs.
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CON Action Number: 10056
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
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