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CON2014042 Main Application y '' a r 11 E., cFL'ulA nYPHa Georgia ;444f)1 1�COMMUNITYH 'I'f( Certificate of Need Applicationcj, �' FOR DIVISION OF HEALTH PLANNING USE ONLY PROJECT NUMBER DATE STAMP RECEIVED GA 2 0 1 4 . 0 4 2 OCT 032014 Office of Health Planning Healthcare Family Regulation Division Georgia Department of Community Health COUNTY: Signed Original and 1 Copy Fee Verified GENERAL INFORMATION: The Certificate of Need (CON) application is the required document that the Department reviews in the analysis and evaluation of proposed projects to establish or expand healthcare services and facilities in accordance with CON Administrative Rule 111-2-2. Requests to develop or offer new institutional health services must be completed and submitted only on the Department's application and supplemental forms provided, which are available at the Department's website, www.dch.georgia.gov. 1. Applicants must submit a signed original and one (1) copy of the signed application and the appropriate filing fee. 2. The filing fee shall be made payable to the "State of Georgia" and shall be remitted by Certified Check or Money Order. 3. Failure to submit the required filing fee, the original application, and the single copy will result in non- acceptance of the application. 4. Applications received after 3 p.m. will be deemed accepted the next business day. PLEASE COMPLETE THE FOLLOWING TABLE TO VERIFY PROPER SUBMISSION OF YOUR APPLICATION Applicant Legal Name: Bartow County Holdings, LLC 1. Have you submitted an original signed in blue ink and provided one (1) copy of ® Yes this signed application? ❑ No 2. Enter Total Cost Applicable to Filing Fee (From Line 16, Question 22, Page 13) $9,265,895 3. Calculate the Filing Fee and Total Amount Due (Check one of the following and enter the amount in the column to the right) ❑ Line 2 is between 0 to$1 million 4 Enter$1,000.00 $9,266 ® Line 2 is between $1 million and $50 million 4 Enter Line 2 x .001 ❑ Line 2 is greater than $50 million 4 Enter$50,000.00 4. Have you submitted a Certified Check or Money Order made payable to "State ® Yes of Georgia" for the amount listed in Line 3 above? ❑ No Submit to: Division of Health Planning Department of Community Health 2 Peachtree Street, NW—5th Floor Atlanta, GA 30303 OCT 3'14 11X56 Morris Bank CASHIER'S CHECK 46488 301 BELLEVUE AVENUE DUBLIN, GA 31021 10/2/2014 RECONCILIATION Notice to Purchaser:As a condition to this institution's issuance of this check Operator Cheryl Y. Thomas Purchaser agrees to provide an idemnity Bond prior to the refund or replacement Branch Gray of this check in the event it is lost,misplaced,or stolen Purchaser: BARTOW COUNTY HOLDINGS, LLC 213 THIRD ST MACON GA 31202-0000 Payee: DIVISION OF HEALTH PLANNING DEPARTMENT OF COMMUNITY HEALTH 2 PEACHTREE ST, NW-5TH FLOOR ATLANTA, GA 30303 Ameount: $9,26$0. .00 Total: $9,266.00 Payee Memo: Purchaser Memo: Bank Memo: fiaE-YH:IXel y.1.01i4sii411`ilki:IeV[•11020 kteZH:EIJ.M•11.l4a-94Ne1aYfiay4eitilnallU4/_111114/K M:7elN S PO Box 520 (MORRISXiO40 CASHIER'S CHECK 4548:6 BANK 478.272.5202 .... . BARTOW COUNTY HOLDINGS,LLC Purchaser.Memo. Memo: Nine_Thousand Two Hundred Sixty-Six dollars 10/212014 .$9.266,00 Pay DIVISION OF HEALTH PLANNING To The Order Op EPARTMENT OF COMMUNITY HEALTH 2 PEACHTREE ST, NW-5TH FLOOR ATLANTA,GA 30303 u'46481311' 1:06 L 2 L 304 3':506.0 Lu' COMPLETENESS CHECKLIST Please complete the following checklist to ensure that you have included all necessary materials to deem your application complete. Please note that completion of this checklist does not mean that your application is indeed complete as the Department will need to verify the adequacy and completeness of the materials provided. Nevertheless, this checklist should prove helpful as a way to double check before submission of your application. Item Required I Location Check if Check Included if N/A Question 3, Page 1 Copy of Licenses/Permits(for existing facilities) & Attached at APPENDIX B ® ❑ Authorization to Conduct Business Question 8, Page 3-4 &i Attached at APPENDIX C Lobbyist Disclosure Question 13, Page 6 0 Documentation of Site Entitlement Question 17, Page 8 & Attached at APPENDIX D Detailed Description of the Proposed Project Question 18, Page 9 Financial Program Questions 22, Page 13 Equipment Purchase Orders/Invoices Question 22, Page 13 ❑ &f7 Attached at APPENDIX G Proof of Necessary Financing Question 23, Page 14El & Attached at APPENDIX G Financial Statements Question 24, Page 14El & Attached at APPENDIX G Financial Pro Forma Question 25, Pages 15-19 Question 32, Page 26 Architect Cost Estimates(Certified within 60 days) & Attached at APPENDIX I ® ❑ Schematic Plans Question 32, Page 26 ® ❑ & Attached at APPENDIX I Question 48, Page 37 et seq. All Applicable Service-Specific Review Considerations & Attached at APPENDIX N etc. ❑ Signature on Original(In Blue Ink) Page 39 ® 0 Have you submitted a copy of this application to the County Commission in the County where the project will be located? Proof of such submission must be included with this application. Attach ®YES 0 NO such proof at APPENDIX A. Have you submitted one(1)original signed application and one(1)copy of said application?The 1 YES ❑ NO copy must include a copy of the signature at Page 39. Have you included the appropriate filing fee as calculated and reported on the cover page of this ®YES ❑ NO application? The filing fee must be made payable by Certified Check or Money Order. Have all required surveys of the Applicant and any and all affiliate organizations been submitted to ®YES ❑ NO the Division of Health Planning for the most recent three(3)years? Has post-approval reporting for any and all previous Certificate of Need projects of the Applicant and any and all affiliate organizations been submitted to the Certificate of Need Program, if such ®YES ❑ NO reporting is due? Has the Applicant and any and all affiliate organizations satisfied previous indigent and charity care ®YES ❑ NO commitments? Has the Applicant satisfied any and all fines, if any,which have been levied by the Department for ®YES ❑ NO violation of the Certificate of Need Rules or Statute? State of Georgia:Certificate of Need Application Completeness Checklist Form CON 100 Page ii Revised July 2008 INSTRUCTIONS 1. Please read all instructions and review the application forms before attempting to complete and submit the application. 2. A CON application must be submitted on the Department's application and supplemental forms only. Supplemental forms are provided for letters of opposition, additional and amended information. These forms may be obtained on the Department's website: www.dch.georgia.gov. 3. In completing the CON application, if a particular rule or consideration requires substantiating documents such as a finance letter or architect's letter as an appendix, the requested documents must be placed with the noted appendix without exception and must conform to the Instructions for Organization of Appendices on the next page of these instructions. 4. This application must be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 5. All questions must be answered. If a question is not applicable, so indicate. 6. Throughout this application, the following symbols are utilized for emphasis: [ 7 Emphasizes instances where supporting documentation is requested and required to be attached into an Appendix; and Emphasizes important instructions or notes that should be adhered to. 7. A signed original application (in the correct organizational structure) and one (1) copy are required in addition to the appropriate filing fee for an application to be accepted by the Department. Please review the CON administrative rules for detailed explanation of appropriate fees, filing dates and times. 8. The signed original CON application and the single copy must be submitted on loose leaf, one-sided 8 1/2 by 11-inch paper only. The single copy and the original should be rubber banded to separate the copy and the original. • The signed original must not be hole punched nor stapled or otherwise bound. • The single copy must be three-hole-punched but must not be stapled or otherwise bound. 9. Faxed copies of documents and information are not official and must be followed- up with the original documents for inclusion in a project master file. 10. If you are seeking an emergency review per Rule 111-2-2-.07(1)(k), include a cover letter behind the main cover page of this application expressing the reasons that an emergency review should be granted. State of Georgia:Certificate of Need Application Instructions Form CON 100 Page iii Revised July 2008 INSTRUCTIONS FOR ORGANIZATION OF APPENDICES The organization of appendices is mandated by this application and the Table of Appendices that follows. APPLICANTS MUST NOT VARY FROM THIS ORGANIZATIONAL STRUCTURE. 1. Appendices, in the original, as well as, the copies, must be separated by lettered tabs. 2. Each Appendix may have more than one document in which case the Appendix must be separated by COLORED dividing sheets. Please do not use DARK-colored dividing sheets. The dividing sheets must be appropriately labeled with the Appendix Letter and the name of the document that follows the sheet. The documents within such an Appendix should be organized in the order in which they are requested in this application. 3. In the event there are no applicable documents pertaining to a specified Appendix in the table below, include the appropriate lettered tab with a sheet of paper indicating "Not Applicable". TABLE OF APPENDICES Appendix Name Appendix Letter Proof of Submission to County Commission A Licenses/Permits B Organizational Structure C Site Entitlement D Supplemental Need Documentation E Supplemental Existing Alternatives Documentation F Required Financial Feasibility Documentation G Supplemental Effects on Payors Documentation H Architectural Documentation I Required Financial Accessibility Documentation J Supplemental Documentation re: Relationship to Health Care Delivery K System Supplemental Documentation re: Efficient Utilization, Non-Resident Services, Research Projects, Assistance to Health Professional Programs, L Improvements and Innovation, Needs of HMOs, Quality Standards, Resources and Provision of Underreported health services, if applicable. Letters of Support M Required Documentation for Service-Specific Review Considerations N, 0, etc. (See Page 37 and 38 for Explanation) NOTE: Supplemental documentation is documentation such as magazine articles, research papers, newspaper articles, etc., which cannot be reproduced or created in MS Word format. State of Georgia:Certificate of Need Application Instructions Form CON 100 Page iv Revised July 2008 OVERVIEW OF REVIEW PROCESS BATCHED APPLICATIONS: SEQUENCE OF CERTIFICATE OF NEED APPLICATION REVIEW ACTIVITIES 100th Day Application (last day for letters of Day support to be (application 75th Day submitted to complete when (applicant Department) submitted;review provides 120th Day cycle begins same additional (Department Batching day) information) Issues Notice decision) u Pik r 0 0 1 %,10 0 Letter 60-Day 90th Day 110th Day of Meeting (opposition (applicant meeting, provides Intent (applicant applicant can amended only); attend, information; opposition applicant letter(s)due. opposing party must provides provide response to written copy opposition) of argument) ► Batching Notice issued 30 days before Letter of Intent Due ► Letter of Intent received by Department 30 days before application is submitted ► Applications submitted; deemed complete; review cycle begins ► 60-Day meeting (applicant only); deadline for receipt of opposition letter(s) ► 75th day—applicant provides additional information ► 90th day—Opposition Meeting(s)scheduled; applicant can be in attendance; opposing parties must provide written statement of opposition arguments presented (original and one copy to the Department and one copy to the applicant); presentation time will be limited; Department reserves right to make additional inquiries subsequent to 60-day meeting and following opposition meeting. ► 100th day Last day for letters of support to be submitted to the Department ► 110th day Applicant deadline for submitting amended information; applicant deadline for providing written response to opposition due to Department; applicant deadline for providing written response to Department's inquiries subsequent to opposition meeting 120th day Decision issued (No discretion to extend) State of Georgia:Certificate of Need Application Review Process Form CON 100 Page v Revised July 2008 NON-BATCHED APPLICATIONS: SEQUENCE OF CERTIFICATE OF NEED APPLICATION REVIEW ACTIVITIES Application 100th Day 120th deemed 75th Day (last day for Day complete letters of (Depart- (applicant (review cycle support to be ment provides Letter of begins) additional submitted to Issues Intent information) Department) decision) : '''''''' ' ' ' ' ::- : ' : ' : ' : ' 17'':',-: ' '' ': . ' :': :':':';:::' I:•:; ':;: : :: ::::;:!:0: 4'� k. # �Xy ''Sas Application 60-Day 90th Day 110th Day 150th ;' submitted(10 (opposition (applicant Day days to review for Meeting meeting(s) provides (project completeness) deadline f lfor only); scheduled; amended can be deadne information; receipt of applicant can extended) opposition letter(s) attend,opposing applicant parties must provides provide written response to copy of opposition) argument) ► Letter of Intent received by Department 30 days before application is submitted ► Application submitted (10 working days to review for completeness) ► Application deemed complete; 120-day review cycle begins ► 60-day meeting (applicant only); deadline for receipt of opposition letter(s) ► 75th day applicant provides additional information ► 90th day—Opposition Meeting(s)scheduled; applicant can be in attendance; opposing parties must provide written statement of opposition arguments presented (original and one copy to the Department and one copy to the applicant); presentation time will be limited; Department reserves right to make additional inquiries subsequent to 60-day meeting and following opposition meeting. ► 100th day Last day for letters of support to be submitted to the Department ► 110th day Applicant deadline for submitting amended information; applicant deadline for providing written response to opposition; applicant deadline for providing written response to Department's inquiries subsequent to opposition meeting ►120th day Decision issued (Department has discretion to extend to 150th day) State of Georgia:Certificate of Need Application Review Process Form CON 100 Page vi Revised July 2008 Section 1 : General Identifying Information 1. Enter the following information for the person or entity that will offer or develop the new institutional health service. If applicable, this information should correspond with the information submitted to the Department of Human Resources as the "Name of the Governing Body." The contact person should be a person directly affiliated with the Applicant and not a consultant or attorney. APPLICANT Applicant Legal Name: Bartow County Holdings, LLC d/b/a (if applicable): Address: 213 3rd Street City: Macon State: GA Zip: 31201 County: Bibb Main Business Phone: 478 314 1560 Parent Organization: Health Systems Real Estate, Inc CONTACT PERSON Name: Stelling Nelson Title or Position: Authorized Rep. Phone: 478 314 1560 ext. 2261 Fax: E-mail Address: snelson@hsd-ga.org 2. Is the name of the facility or proposed facility different than the Applicant's legal name? ® YES ❑ NO If YES 4 Enter the facility information below. If applicable, this information should correspond to the "Name of Facility" maintained by the Department of Human Resources. If NO 4 Continue to the next question. FACILITY Facility Name: Townsend Park Health and Rehabilitation Facility Address: 196 N. Dixie Avenue City: Cartersville State: GA Zip: 30120 County: Bartow Phone: 770 387 0662 3. If the facility is currently existing, is it currently licensed or permitted by the Department of Human Resources? ®YES ❑ NO ❑ Not Applicable If YES 4 Attach a copy of any and all licenses and permits at APPENDIX B. If NO 4 Continue to the next question. If Not Applicable 4 Check one of the following: ❑ Not Currently Existing (Proposed Only) ❑ No License or Permit Required State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 1 Revised July 2008 4. Is the legal owner of the facility different than the Applicant? ❑ YES ® NO If YES 4 Identify the legal owner and all individuals or entities that own 10 percent interest or more in the facility. Include complete names, addresses, and telephone numbers. If NO 4 Continue to the next question. OWNER#1 Name: County of Bartow— Bartow County Commission Address: 135 W Cherokee Avenue, Ste 251 City: Cartersville State: Georgia Zip: 30120 Phone: 770 387 5030 OWNER#2 Name: Address: City: State: Zip: Phone: OWNER#3 Name: Address: City: State: Zip: Phone: 5. Check the appropriate box to indicate the type of ownership of the Facility. Check only one box. I-- a ❑ Not-for-Profit Corporation w X w Q ® Public(Hospital Authority or Government) I— ❑ General Partnership ❑ Business Corporation ❑ Sole Proprietor Z T- a )C ❑ Limited Liability Partnership ❑ Limited Liability Corporation State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 2 Revised July 2008 6. Will the entire facility be operated by an entity other than the Applicant or the legal owner? ® YES ❑ NO If YES 4 Identify the operator and include the complete name, address, and telephone number. If NO 4 Continue to Question 8. OPERATOR Name: Townsend Park Health and Rehabilitation, LLC d/b/a Townsend Park Health and Rehabilitation Address: 1005 Boulder Drive City: Gray State: GA Zip: 31032 Phone: 770 387 0662 7. Check the appropriate box to indicate the type of operator. Check only one box. ® Not-for-Profit Corporation X w X ❑ Public(Hospital Authority or Government) H ❑ General Partnership ❑ Business Corporation ❑ Sole Proprietor z a X ❑ Limited Liability Partnership ❑ Limited Liability Corporation 8. Please provide documentation of the organizational and legal structure of the Applicant as indicated in the table below. 17 Attach this documentation as APPENDIX C. Please attach the documents in the order they are listed. ORGANIZATIONAL STRUCTURE ® Name of Each Officer and Director ®Articles of Incorporation Not-for-Profit ® Certificate of Existence Corporation ® Bylaws ® Organizational Chart(s) ❑ Application/Authorization to do Business in Georgia (for Non-Resident Corporations) Public ❑All Governing Authority Approvals for this Application and Project (Hospital Authority ❑ Bylaws or Government) ❑ Organizational Chart(s) State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 3 Revised July 2008 ORGANIZATIONAL STRUCTURE ❑ County and Municipal Government Business Authorization Documents Sole Proprietor (e.g. Licenses, Permits, Etc.) ❑ Bylaws ❑ Organizational Chart(s) ❑ Name, Partnership Interest, and Percentage Ownership of Each Partner ❑ Partnership Agreement General Partnership ❑ Certificate of Existence ❑ Bylaws ❑ Organizational Chart(s) ❑ Name, Partnership Interest, and Percentage Ownership of Each Partner ❑ Partnership Agreement Limited Liability ❑ Certificate of Existence Partnership 1:1Certificate of Registration ❑ Articles of Organization ❑ Bylaws ❑ Organizational Chart(s) ❑ Name of Each Officer and Director ❑ Articles of Incorporation Business ❑ Certificate of Existence Corporation ❑ Bylaws ❑ Organizational Chart(s) ❑ Application/Authorization to do Business in Georgia (for Non-Resident Corporations) ❑ Name of Each Officer and Director ❑ Articles of Incorporation ❑ Operating Agreement Limited Liability ❑ Certificate of Existence Corporation ❑ Bylaws ❑ Organizational Chart(s) ❑ Application/Authorization to do Business in Georgia (for Non-Resident Corporations) 9. If you have identified the Applicant as a Not-for-Profit Corporation, Business Corporation, or Limited Liability Corporation, explain the corporate structure and the manner in which all entities relate to the Applicant. NOTE: Do not exceed the allotted space for your response. Bartow County Holdings, LLC is a Limited Liability Corporation of which Health Systems Real Estate, Inc. is the single member. Townsend Park Health and Rehabilitation, LLC dba Townsend Park Health and Rehabilitation sub-leases the facility from Bartow County Holdings, LLC. Townsend Park Health and Rehabilitation, LLC dba Townsend Park Health and Rehabilitation controls and directs all aspects of operations of the current center as a licensed skilled nursing center. State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 4 Revised July 2008 10. Does the Applicant have Legal Counsel to whom legal questions regarding this application may be addressed? ❑ YES ® NO If YES -4 Identify the lead attorney below. If NO -4 Continue to the next question. LEGAL COUNSEL Name: Firm: Address: City: State: Zip: Phone: Fax: Email: 11. Did a Consultant prepare and/or provide information in this application? ❑YES ® NO If YES 4 Identify the Consultant below. If NO 4 Continue to the next question. CONSULTANT Name: Firm: Address: City: State: Zip: Phone: Fax: Email: 12. Does the Applicant wish to designate and authorize an individual other than the Applicant Contact listed in response to Question 1 to act as the representative of the Applicant for purposes of this application? E YES ❑ NO If YES 4 Please complete the information in the table on the next page. By doing so, the Applicant authorizes the representative to submit this CON application and make amendments thereto; to provide the Department of Community Health with all information necessary for a determination on this application; to enter into agreements with the Department of Community Health in connection with this CON; and to receive and respond, if applicable, to notices in matters relating to this CON. If NO 4 Continue to the next question. State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 5 Revised July 2008 AUTHORIZED REPRESENTATIVE Name: Stelling Nelson Firm: Health Systems Development, LLC Address: 4931 Riverside Drive, Suite 100 A City: Macon State: GA Zip: 31210 Phone: 478 314 1560 ext. 2261 Fax: Email: snelson@hsd-ga.org NOTE: This authorization will remain in effect for this application until written notice of termination is sent to the Department of Community Health that references the specific CON application number. Any such termination must identify a new authorized representative. Also, if the authorized representative's contact information changes at any time, the Applicant must immediately notify the Department of Community Health of any such change. 13. Does the Applicant have any lobbyist employed, retained, or affiliated with the Applicant directly or through its contact person or authorized representative? ❑ YES ® NO If YES 4 Please complete the information in the table below for each lobbyist employed, retained, or affiliated with the Applicant. Be sure to check the box indicating that the Lobbyist has been registered with the State Ethics Commission. Executive Order 10.01.03.01 and Rule 111-1-2- .03(2) require such registration. If NO 3 Continue to the next question. LOBBYIST DISCLOSURE STATEMENT Affiliation with Registered with Name of Lobbyist Applicant State Ethic Commission? ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No • ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No ❑ Employed ❑ Yes ❑ Other Affiliation ❑ No State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 6 Revised July 2008 Section 2: Project Description 14. Indicate the type of facility that will be involved in the project. FACILITY TYPE ❑ Birthing Center 0 Hospital ❑ Continuing Care Retirement Community (CCRC) ® Nursing or Intermediate Care Facility ❑ Freestanding Ambulatory Surgery Center ❑ Personal Care Home ❑ Home Health Agency 0 Traumatic Brain Injury Facility ❑ Diagnostic, Treatment or Rehabilitation Center(DTRC) ❑ Freestanding Single-Modality Imaging Center ❑ Freestanding Multi-Modality Imaging Center ❑ Mobile Imaging 0 Practice-Based Imaging ❑ Other: 15. Indicate the services that will be involved or affected by this project. SERVICES Hospital Inpatient Diagnostic Services ❑ Medical/Surgical ❑ Computerized Tomography(CT)Scanner ❑ Open Heart Surgery ❑ Magnetic Resonance Imaging (MRI) ❑ Pediatric ❑ Positron Emission Tomography(PET) ❑ Obstetrics 0 Diagnostic Center, Cancer/Specialty ❑ ICU/CCU ❑ Newborn, ICU/INT Other Outpatient Services ❑ Newborn/Nursery ❑ Ambulatory Surgery 0 Rehabilitation ❑ Birthing Center V ❑ Acute, Burn, Other Specialty ❑ Long Term Acute Care I Clinical/Surgical ❑ Inpatient, Other ❑ Emergency Medical ❑ Psychiatric,Adult ❑ Emergency Medical,Trauma Center ❑ Substance Abuse,Adult ❑ Adult Cardiac Catheterization ❑ Psychiatric, Child/Adolescent 0 Gamma Knife ❑ Substance Abuse, Child/Adolescent ❑ Lithotripsy ❑ Psychiatric, Extended Care ❑ Pediatric Cardiac Catheterization ❑ Destination Cancer Hospital ❑ Megavoltage Radiation Therapy ® Skilled Nursing Care 0 Personal Care Home zw ® Intermediate Nursing Care 0 Traumatic Brain Injury(TBI) O I ❑ Continuing Care Retirement Community (CCRC) 0 Home Health ❑ Administrative Support 0 Grounds/Parking _ 0 Non-Patient Care, Other 0 Medical Office Building O State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 7 Revised July 2008 16. Check the most appropriate category(ies)for this project. Check all that apply. PROJECT CATEGORY Construction Service Change ❑ New Facility ❑ New Service ❑ Expansion of Existing Facility ❑ Expansion of Service ® Reconstruction of Existing Facility ❑ Expansion or Acquisition of Service Area ® Replacement of Existing Facility ❑ Consolidation of Service I ❑ Relocation of Facility Procurement of Medical Equipment ❑ Other ❑ Purchase ❑ Lease ❑ Donation (fair market value must be used) 17. Please provide the following site information for the facility and services identified in this application. Check the appropriate box to indicate the current status of the site acquisition. Attach the appropriate documents that provide for the Applicant's entitlement to the site at APPENDIX D. NOTE: If an unsigned lease is attached, include a letter documenting both parties' commitment to participate in the lease once the CON is approved, if applicable. PROJECT SITE INFORMATION Street Address: 196 N Dixie Avenue City: Cartersville County: Bartow Zip: 30120 Number of Acres: 6.56 Status of Site Acquisition ❑ Purchased (attach deed) ® Leased (attach lease) ❑ Under Option(attach option agreement) ❑ Under Contract(attach contract or bill of sale) ❑ Other; please specify: Zoning Is the site appropriately zoned to permit its use for the purpose stated within the application? ® YES ❑ NO If NO 4 Describe what steps have been taken to obtain the correct zoning and the anticipated date of re-zoning: Encumbrances Are there any encumbrances that may interfere with the use of the site, such as mortgages, liens, ❑ YES assessments,easements, rights-of-way, building restrictions,or flood plains? ® NO State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 8 Revised July 2008 18. Provide a detailed description of the proposed project including a listing of the departments (e.g. ED, ICU), services, (e.g. Home Health, Cardiac Cath), and equipment(e.g. MRI, PET, Cath) involved. NOTE: If your description exceeds this blocked space, attach additional 8-X by 11-inch pages, number the first sheet Page 9.1, the second Page 9.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 9.1, etc. behind this Page 9. This project is the replacement and reconstruction of a 124 bed existing skilled nursing facility in Cartersville, Georgia. The project consists of the addition of 30 private patient rooms, Town Square Therapy suite, administrative suite, new kitchen, dining room, covered entry, and other ancillary support space. It also includes the replacement and reconstruction of the remainder of the existing building. The existing facility will be reconfigured as appropriate to meet the current and future expectations of the healthcare consumer. The initial concept is to complete the new construction first and then work with facility operations to undertake an aggressive phasing plan for renovation of the remainder of the facility. The site will be configured with a covered visitor and patient entry into the center. Parking is being configured to allow convenient access to visitors. Attractive courtyards for use by patients are part of our site planning. Exterior landscape enhancements are planned to enhance the centers visibility in the community. We will work with local authorities having jurisdiction to ensure compliance with storm water management practices. The building's overall energy efficiency is being carefully evaluated for enhancement opportunities including replacement of current windows with high efficiency windows, the use of high efficiency water heating, HVAC upgrades with high efficiency equipment, energy recovery management of air exchange, and building insulation. All new construction portions of this project will be designed to meet all energy efficiency codes. The addition of a new efficiently designed kitchen allows us to decentralize the dining program. Decentralization of dining allows us to provide a more pleasant and patient focused dining experience. Living rooms are located closer to the patient rooms to allow for smaller congregation areas and to allow for more focused and individualized resident activities. Bathing facilities are scheduled for complete reconstruction so the center can offer an appealing bathing experience to the patients. Staff offices are positioned throughout the center to allow for support and supervision of patients. Storage spaces are located to increase facility staff operating efficiency as they serve the patients. Patient lift storage is being incorporated strategically to allow for convenient access by staff members to serve patients. The patient nurse call system will be replaced with an efficient and modern patient nurse call system. The system will include voice communication to patient rooms as well as staff pagers to quickly notify staff of a patient call. This system will enhance efficiency of the staff in service to the patients. The entire center is being evaluated for enhancements to door security and access. The project will include a 26 bed secured memory care unit that will include 11 semi private rooms and 4 private rooms. The memory care unit is an enhancement in service to this special needs population and will offer specialized care to this growing segment of healthcare need in the community. The interiors throughout the center will be professionally coordinated by a team of interior designers. Interiors will be coordinated to standards that enhance the overall comfort and appeal to the patients served and will include coordinated colors and lighting enhancements. When the project is complete there will be a total of 78 private rooms and 23 semi private rooms. The total possible occupancy following renovation remains at 124 patients. In conclusion, the existing center will receive a full makeover that will allow it to serve patients for many years in the future. This CON is for a capital expenditure over the CON threshold. No new institutional health service is planned. State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9 Revised July 2008 Section 3: General Review Considerations All Certificate of Need applications are evaluated to determine their compliance with the general review considerations contained in Rule 111-2-2-.09. Please document how the proposed project conforms with the following general review considerations. Rule 111-2-2-.09(1)(a): Consistency with State Health Plan The proposed new institutional health services are reasonably consistent with the relevant general goals and objectives of the State Health Plan. 19. Explain how the project is consistent with the State Health Plan or why it does not apply. Also explain how the application is consistent with the Applicant's own long range plans. NOTE: If your explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 10.1, the second Page 10.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 10.1, etc. behind this Page 10. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. This facility is currently operating under a 124 bed skilled nursing facility Certificate of Need. The Applicant requests to reconstruct and replace the current center in the current location of operation. Applicant will continue to operate as a 124 bed skilled nursing facility following the reconstruction and replacement in the current location. The proposed project is consistent with the State Health Plan because it will provide a modern and efficient health care setting in which to deliver cost effective skilled nursing services. The project is consistent with the Applicant's long range plan to provide skilled nursing services in a modern healthcare facility environment while preserving a homelike look and feel in which to deliver skilled nursing services. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 10 Revised July 2008 Rule 111-2-2-.09(1)(b): Need The population residing in the area served, or to be served, by the new institutional health service has a need for such services. 20. Please explain the need for your particular project or service. For services for which a need methodology exists in the State Health Plan, please use the said methodology. In submitting information to explain the need for your project, please also use the following guidelines: • For any population projections,the official projections of the Office of Planning and Budget should be utilized; • Include maps that clearly define both the primary and secondary service areas and identify all other providers of the proposed service that lie within the primary and secondary service area on such maps; • Describe the relationship of the site to public transportation routes, if any, and to any highway or major road developments in the area. Describe the accessibility of the proposed site to patients/clients, visitors, and employees;and • For services that already have documented utilization rates, include such historical utilization data, and projections for future utilization. NOTE: If your explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 11.1, the second Page 11.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 11.1, etc. behind this Page 11. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that supports the need for your project into APPENDIX E. All documents such as tables, charts, and maps that support your need analysis and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The center primarily serves Bartow County but does have admissions from surrounding counties as well as other areas of the State of Georgia. Please see page 11.1 for counties of admission origin for the past two years as reported from the Annual Nursing Home Questionnaire. The Governor's Office of Planning projects steady population increases for Bartow County in the years to come. Please see table on Page 11.2 The Governor's Office of Planning projects steady population increases in people over the age of 65 in Bartow County. The primary users of skilled nursing service in our state are people age 65 and over. Please see table on page 11.3. These population trends indicate a growing need for the established skilled nursing service in the community. This center has maintained stable occupancy over the past three years. See page 11.4 for center specific occupancy trend over the past three years. This project is designed to provide an updated and enhanced physical plant environment to meet the expectations of today's customers as well as future customers from the defined service area. The therapy service area is increased in size within the existing square footage. This allows for enhancements in equipment and specialized therapy service areas to meet the therapy needs of patients in the defined service area. Upgrades to the nurse call system and other special systems enhance the communications between patients and staff members in the facility. Upgrades in mechanical systems will provide improvements in air quality and comfort ranges in air temperatures. Lighting upgrades throughout the center are designed to meet the recommended ranges for patients typically served in skilled nursing centers. The interior scheme will give the center a more pleasant appearance that is sure (see 11.5) State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 11 Revised July 2008 Bartow County Holdings, LLC Certificate of Need Source of Admissions for the last two years by county per Annual Nursing Home Questionnaire. Year: 2014 Year: 2013 County Number of Patients County Number of Patients Bartow 92 Bartow 81 Cherokee 2 Cherokee 1 Cobb 13 Cobb 16 Floyd 2 Floyd 4 Forsyth 1 Fulton 1 Fulton 1 Gordon 3 Gordon 3 Jasper 1 Jasper 1 Muscogee 1 Muscogee 1 Paulding 2 Paulding 1 Pickens 1 Pickens 1 Polk 1 � � ,e,,, ,,,�� a�-R.. ', (,iiG.,�G/�vi .,i✓� /� P. O}a I �� '4'( 8H tai Nii�,����tv:��..zea ✓6�.,r���l„IIEi yi/�il�i,��:;�<�a�o,„��i''�,�/.lilcii✓uo„��, ., a „iai; Page 11.1 Bartow County Holdings, LLC Certificate of Need Population projections for the county from the Governor's Office of Planning: County 2015 2016 2017 2018 2019 2020 Bartow 110,206 112,299 114,393 116,488 118,580 120,673 Page 11.2 Bartow County Holdings, LLC Certificate of Need Population projection for the county residents over age 65 from the Governor's Office of Planning: County 2015 2016 2017 2018 2019 2020 Bartow 13,333 13,959 14,586 15,213 15,839 16,465 Page 11.3 Bartow County Holdings, LLC Certificate of Need Facility specific occupancy percentages for the most recent three years as reported on the Medicai Cost Report. 2012 2013 2014 Total Occupancy Percentage 96.10% 93.60% 94.10% Page 11.4 Bartow County Holdings, LLC Certificate of Need to be much appreciated by the customers served in the center. The covered entry allows customers to have a protected entry point during inclement weather. The improved exterior grounds will give customers from the service area more pleasing and accessible exterior areas for relaxation and visitation with guests. Improvements to the parking lot will better serve the customers from the defined service area in allowing them safe and well lit areas to park for visitation of patients from the defined service area. All aspects of this project are being undertaken to prepare this facility to better serve patients from the community and the defined service area if and when they require services of a skilled nursing facility in Bartow County, Georgia. Page 11.5 Rule 111-2-2-.09(1)(c): Existing Alternatives Existing alternatives for providing services in the service area the same as the new institutional health service proposed are neither currently available, implemented, similarly utilized, nor capable of providing a less costly alternative, or no Certificate of Need to provide such alternative services has been issued by the Department and is currently valid. 21. Identify existing health care facilities and services and those approved for development in the service or planning area. Describe how your service differs in terms of population served from the existing and approved services. Describe how the proposed project will enhance service delivery in the service or planning area. Also, explain the internal organizational alternatives that the Applicant considered. NOTE: If your explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 12.1, the second Page 12.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 12.1, etc. behind this Page 12. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of existing alternatives into APPENDIX F. All documents such as tables, charts, and maps that you wish to use to analyze the existing alternatives and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The alternative is to not reconstruct and replace the building and not provide the patients with an updated more homelike environment. The applicant is committed to the long-term future of the skilled nursing services provided to patients in this center. This project demonstrates that commitment to the community by investing in the building. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 12 Revised July 2008 Rule 111-2-2-.09(1)(d): Financial Feasibility The project can be adequately financed and is, in the immediate and long-term, financially feasible. 22. Provide project cost estimates for the following categories. Enter in whole dollar amounts except Cost/Sq. Ft. PROJECT COST ESTIMATES Type of Cost Amount Sq. Ft. Cost/Sq. Ft. COSTS APPLICABLE TO FILING FEE Construction (1) New Facility Costs 4,626,625 28,075 164.80 (2) Expansion Costs (3) Reconstruction Costs 3,265,925 50,245 65.00 (4) Architectural and Engineering Fees 496,590 (5) Subtotal Construction 8,389,140 4— Add Lines 1 through 4 Equipment Attach Purchase Orders or (6) Fixed Equipment(not in construction contract) Quotes for All Major Medical (7) Moveable Equipment Equipment at APPENDIX G. (8) Subtotal Equipment 0 Add Lines 6 through 7 Other (9) Contingency 851,755 (10) Legal and Administrative Fees 25,000 (11) Interim Financing (12) Underwriting Costs (13) Building and Fire Code Compliance (14) Other: (15) Subtotal Other I 876,755 4— Add Lines 9 through 14 (16)TOTAL COST APPLICABLE TO FILING FEE 9,265,895 4 — Add Lines 5, 8 and 15 COSTS EXCLUDED FROM FILING FEE NOTE: (17) Site Acquisition Cost Enter the Amount of Line 16 (18) Predevelopment Costs 90,000 on the Cover Page at Item 2 of the Submission Table. (a) Preparation of Site 625,000 (b) Development and Preparation of CON Application 35,000 (19)Subtotal Predevelopment 750,000 Add Lines 18a and 18b (20) Escrow for Debt Service (21)TOTAL COST EXCLUDED FROM FILING FEE 750,000 ♦— Add Lines 17, 19, and 20 (22) GRAND TOTAL ESTIMATED PROJECT COST 10,015,895 4-- Add Lines 16 and 21 NOTE: Use the amount of Line 22 for all responses throughout this application except for calculating the filing fee. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 13 Revised July 2008 23. Indicate the anticipated sources of funds for the proposed capital expenditures if any. Specify the amount received from each source. Round to whole dollar amounts. Attach documentation indicating the current availability of grants, private contributions, and unrestricted reserves, if any, at Appendix G. Fund Sources If you enter debt financing sources, provide the following in Source Amount APPENDIX G: 1. Contingency letters of DEBT commitment from a bank or other reputable lending (1) Revenue Certificates institution(s)indicating its interest in financing the project (2) General Obligation Bonds if a Certificate of Need is issued to the Applicant that (3) Commercial Loans states the anticipated terms, including the interest rate, (4) Government Loans frequency of payments,total amount to be borrowed, and EQUITY the duration of the financial obligation. (5) Grants 2. Amortization schedules including the interest, (6) Private Contributions (Philanthropy) principal,depreciation and amortization by year. (7) Public Campaign (8) Unrestricted Reserves on Hand 10,015,895 (Cash) (9) Other(please specify): (10)TOTAL ESTIMATED FUNDS 10,015,895 ♦— Add Lines 1 through 9 NOTE: The amount of Line 10 should equal the amount of Line 22 of Question 22 above! 24. Does the Applicant undergo annual financial audits? ® YES ❑ NO If YES 4 Attach the most recent financial audit at APPENDIX G. If NO 4 Please provide Balance Sheets, Bank Statements, Tax Returns, or other financial statements verifying income. Attach this documentation in APPENDIX G. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 14 Revised July 2008 25. Provide pro forma income and expense projections for the first two years of operation following the anticipated completion of the project. Identify all the assumptions used to develop the pro forma statement. Indicate the period covered for the first and second years. Pro Forma Income and Expense Projections Type of Income or Expense First Year(mm/yy) Second Year(mmiyy) Period Covered(Month and Year) 6/17 to 5/18 6/18 to 5/19 (1) Number of 124 124 Beds/Rooms/Procedures/Patients (2) Projected Percent Occupied or Utilized 93 % 95 ok REVENUES (3) Inpatient Revenues 11,300,337 12,189,851 (4) Outpatient Revenues 230,394 230,394 AddLines3and4 (5) Patient Revenues 11,530,731 12,420,245 I (6) Other Revenues 39,720 39,720 Add Lines Sand 6 (7) GROSS REVENUES 11,570,451 12,459,965 Deductions From Revenues (8) Indigent and Charity Care (9) Bad Debt (10) Contractual Adjustments Medicaid 1,309,489 1,377,958 Medicare (165,770) (107,547) Other 99,630 154,260 (11) Other Free Care Add Lines 8,9,10&11 (12)TOTAL DEDUCTIONS 1,243,350 1,424,670 Subtract Line 12 from Line 7 (13) NET REVENUES $10,327,101 $11,035,295 EXPENSES Direct Expenses (14) Salaries and Benefits 5,368,141 5,496,817 (15) Supplies 1,119,887 1,178,230 (16) Other 1,144,762 1,306,306 Add Lines 14 through 16 (17) DIRECT EXPENSES 7,632,790 7,981,352 Indirect Expenses (18) Depreciation 52,061 52,061 (19)Amortization (20) Interest State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 15 Revised July 2008 Pro Forma Income and Expense Projections Type of Income or Expense First Year(mmiyy) Second Year(mm/yy) Period Covered(Month and Year) 6/17 to 5/18 6/18 to 5/19 (21) Other 2,379,715 2,417,506 Add Lines 18 through 21 (22) INDIRECT EXPENSES 2,431,776 2,469,567 Add Lines 17&22 (23)TOTAL EXPENSES $10,064,566 $10,450,919 INCOME/ (LOSS) Subtract Line 23 from Line 13 (24) Income I(Loss) $262,536 $584,376 (25) Income Taxes Subtract Line 25 from Line 24 (26) NET INCOME/(LOSS) $262,536 $584,376 GROSS PATIENT REVENUE BY SOURCE Government (27) Medicare 2,693,649 3,111,706 (28) Medicaid 6,443,976 6,438,960 (29) Other Government Add Lines 27 through 29 (30) Government $9,137,625 $9,550,666 Nongovernmental (31) Third Party Payors 833,527 1,165,940 (32) Self-Pay 1,559,579 1,703,640 (33) Other Nongovernmental Add Lines 31 through 33 $2,393,106 $2,869,580 (34) Nongovernmental Add Lines 30 and 34 $11,530,731 $12,420,245 I (35)TOTAL, ALL SOURCES NOTE: These amounts must equal "Patient Revenues"under line 5 on Page 15 State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 16 Revised July 2008 Briefly outline the assumptions made for each line item of statistics entered in the Pro Forma Income and Expense Projections above. PRO FORMA ASSUMPTIONS (1) Number of Beds/Rooms/Procedures/Patients: The proposed project will not change the number of licensed beds operated by Townsend Park. They will maintain its 124 licensed beds subsequent to project completion. Townsend Park expects only a small increase from its historical average census, to 115.6 in year 1 and 117 in year 2. (2) Projected Percent Occupied or Utilized: Occupancy percentage is projected to be 93% in year 1 and 95% in year 2. (3)Inpatient Revenues: Inpatient revenue was based on historic information to calculate the current rates with the assumption of the increase due to this addition for the Medicaid rate. We anticipated a 2% increase in Medicare rates and a 5% increase in private pay rates, which is historically what has been done (4)Outpatient Revenues: Based on what was historically provided and used in our current financial plan. (6)Other Revenues: Based on what was historically provided and used in our current financial plan. (8)Indigent and Charity Care: N/A (9) Bad Debt: Based on the minimal amount from historical data we are currently not planning any bad debt expense. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 17 Revised July 2008 PRO FORMA ASSUMPTIONS (10)Contractual Adjustments: Contractual adjustments are calculated from the difference between the charges at the current semi private rate and ancillary charges to the reimbursable per diem rates. Medicaid rates are adjusted to reflect the expected effect on Medicaid reimbursement as a result of the proposed project. (11)Other Free Care: N/A (14)Salaries and Benefits: Current rates with a 3% increase in wages each year to the starting point of this project completion date. This is based on what raise has historically been given each year. There was an addition of 4.56 FTEs in years 1 and 2. (15)Supplies: Increased most of the supplies account by 3% to 6% the first year. This is an estimate of increased spending and possible supplier increase in their costs. (16)Other: Other direct expenses are based on Townsend Park's historical experience. (18)Depreciation: Depreciation includes both project and existing depreciation. Depreciation for the project was based on an average depreciable life of 10 years for the furniture, fixtures, and equipment purchased. (19)Amortization: N/A (20)Interest: N/A State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 18 Revised July 2008 PRO FORMA ASSUMPTIONS (21)Other Indirect Expense: Other indirect expenses are based on Townsend's Park historical information and were adjusted to reflect the impact of the proposed project. (25)Income Taxes: N/A (27)Medicare: Medicare revenues are projected to be at 27 percent of total patient revenue in year 2, which is a slight increase over historical information due to the addition of the short term therapy rooms for the project. (28)Medicaid: Medicaid revenues are projected to be 46 percent of total patient revenue in year 2, consistent with historical information. (29)Other Government: N/A (31)Third Party Payors: Third party payor revenues are projected to be at 9 percent of total patient revenue in year 2, a slight increase due to the addition of the therapy rooms for the project. (32)Self-Pay: Self-pay revenues are projected to be at 15 percent of total patient revenue in year 2, a slight increase due to the addition of the private rooms from the project. (33)Other Nongovernmental: N/A State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 19 Revised July 2008 26. Provide details of the Applicant's total existing indebtedness in the following table: Associated Origination Outstanding Interest Capital Project Lender Name Date Due Date Principal Rate CON/LNR# (if applicable) No Existing Debt 0/0 0/0 0/0 0/0 • State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 20 Revised July 2008 27. Please provide the following information about staffing levels. Indicate the number of existing and proposed employees for the second operating year following the project's completion. Please express in full-time equivalents. Staffing Levels(Full-Time Equivalents) Position Existing Proposed Total Registered Nurse 9.13 9.13 Licensed Practical Nurse 15.24 15.24 Licensed Nurse Practitioner or Other Advanced Practice Nurse Nurse Midwife Nursing Assistant 43.64 1.32 44.96 Physician Pharmacist Dentist Social Worker 2.01 2.01 Certified Addiction Counselor Audiologist Radiological Technician Surgical Technician Physical Therapist Respiratory Therapist Occupational Therapist Psychologist Speech - Language Pathologist Medical Laboratory Technologist Personal Care Aide Home Health Aide Total Other Staff 36.65 4.56 41.21 State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 21 Revised July 2008 28. Describe plans for securing the services of professional, administrative, and paramedical personnel. Describe the current availability of staff as well as plans for training and recruiting the required personnel. Include institutional agreements and other supporting documents. Do not exceed the space provided. This project is to reconstruct and replace an existing skilled nursing center in full operation serving a patient population that it will continue to serve following the reconstruction and replacement. The building is fully staffed at this time with a full complement of professional, administrative, and paramedical personnel. There are no plans to recruit additional staff positions to serve the reconstructed and replaced center. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 22 Revised July 2008 Rule 111-2-2-.09(1)(e): Effects on Payors The effects of the new institutional health service on payors for health services, including governmental payors, are reasonable. 29. Provide data to show the trend in current and projected charges under the facility's existing operations. For proposed new facilities or services, provide data to show the trend in charges at other facilities that are owned and/or operated by the Applicant, if applicable. NOTE: If your explanation exceeds this blocked space or you need to attach tables or graphs, attach additional 8-%by 11-inch pages, number the first sheet Page 23.1, the second Page 23.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 23.1, etc. behind this Page 23. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the effect on payors of your project into APPENDIX H. All documents such as tables, charts, and maps that you wish to use to analyze the effect on payors and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The Applicant and the Operator do not anticipate the proposed project will have a negative impact on payors. The improvement in the center's physical environment and efficient distribution of services throughout the building will allow the center to provide a tremendous value to the community. Please See Exhibit 29.1 Exhibit 29.1 Rate Projection Year 1 Year 2 Medicare $436.69 $436.69 Medicaid Jun-Sept $173.00 Oct-May$192.58 $192.58 Private Pay Jun is $229.00 Jul-May is$240.00$240.00 for Jun $252.00 for Jul-May Private Insurance $352.92 $352.92 Hospice Jun-Sept $173.00 Oct-May$192.58 $192.58 State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 23 Revised July 2008 Rule 111-2-2-.09(1)(f): Construction Methods and Costs The costs and methods of a proposed construction project, including the costs and methods of energy provision and conservation, are reasonable and adequate for quality health care. 30. Provide the following information about the architect or engineer who has been engaged to design this project. Include documentation of the architect or engineer's registration in Georgia. CHIEF ARCHITECT/ENGINEER Name: Johnny Hembree Firm: Pieper O'Brien Herr Architects Address: 3000 Royal Blvd South City: Alpharetta State: GA Zip: 30022 Phone: 770 569 1706 Registration Number: RA011562 31. Project Completion Forecast. Complete the following project completion forecast. It is important that you supply feasible and well-planned dates because if you do not complete your project or implement your project in a timely fashion, your Certificate of Need will be subject to revocation. For projects that do not involve construction, enter days and dates for those events that are applicable; for example, Equipment Installed and Final Progress Report Submitted. PROJECT COMPLETION FORECAST Event Days Required to Proposed Completion Complete Date 1. Final Architectural Plans and Specifications 180 3/31/2015 2. Plans approved by State Architect 30 4/30/2015 3. Enforceable Construction Contract Signed 15 5/15/2015 4. Building Permit Secured 15 5/30/2015 5. Materials on Site 5 6/5/2015 6. Site Preparation Completed 60 8/1/2015 7. Construction 25% Complete 180 2/28/2016 8. Construction 50% Complete 150 7/31/2016 9. Construction 75% Complete 150 12/31/2016 10. Equipment Installed (If Applicable) N/A 11. Construction 100% Complete 150 5/30/2017 12. License Obtained from DHR Office of Regulatory N/A Services 13. New Institutional Health Service Offered N/A 14. Final Progress Report Submitted 45 7/15/2017 State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 24 Revised July 2008 In addition to the table above, if major components of the proposed project will be completed and become operational prior to the overall completion of the project (for example department or services will be developed in phases) indicate below the anticipated date of completion for each component. Will major components of the proposed project be developed in phases? ® YES ❑ NO If YES 4 Complete the following table. cr NOTE: If your components or phases exceed the number of rows in the table, attach an additional 8-% by 11-inch sheet containing a replica of this table, number the first sheet Page 25.1, the second Page 25.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 25.1, etc. behind this Page 25. If NO 4 Continue to the next question. COMPONENT/PHASED COMPLETION FORECAST Component, Department, or Phase Days Required to Proposed Completion Complete Date Phase 1 — New Construction 180 2/28/2016 Phase 2—Reconstruct Existing 150 7/31/2016 Phase 3— Reconstruct Existing 150 12/31/2016 Phase 4—Reconstruct Existing 150 5/30/2017 NOTE: If litigation regarding this application, and approval thereof, occurs, the completion forecast will be adjusted at the time of the final resolution to reflect the actual effective date, if the final resolution is in favor of the application. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 25 Revised July 2008 32. Please provide the information in the chart below if your project involves any construction or remodeling. l Attach the requested information in APPENDIX I in the order listed in the chart below. Architectural Documents Provide a letter from the architect certifying the construction and/or reconstruction costs for the project. The letter must include the total square 1. Architect footage, the total cost of construction, the cost per square foot for construction, Certification and the cost per square foot for reconstructions. These amounts should match the amounts shown on Lines 1 through 5 of Question 22. This letter must be prepared within 60 days of submission of the application. Provide schematic plans for the project and include at least the following information: • Plans for each floor that clearly show the relationship between departments and services and the room arrangements for each. Indicate the function of each room or space. • Proposed roads, walkways, service courts, entrance courts, parking, and orientation should be shown on either a plot plan or the first floor plan. 2. Schematic Plans • Provide a cross-sectional diagram that indicates the type of construction and building materials. • If the proposed construction is an addition or if it is otherwise related to existing buildings on the site, the schematic plans should show the facilities and the general arrangement of those buildings. NOTE: These plans should be provided on paper no larger than 8 %- in. by 11-in. If such plans cannot be reproduced legibly at this size, the plans must be submitted as a .pdf document on a CD-rom that is included with the application and each copy thereof. Provide a plot plan of the site including at least the following: dimensions of the 3. Plot Plan property lines; the locations of major structures, easements, rights-of-way, and encroachments; the location of the proposed facility or expansion; and the relationship of the facility to additional structures, if any, on the campus. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 26 Revised July 2008 Rule 111-2-2-.09(1)(g): Financial Accessibility The new institutional health service proposed is reasonably financially and physically accessible to the residents of the proposed service area and the Applicant assures there will be no discrimination by virtue of race, age, sex, handicap, color, creed, or ethnic affiliation. 33. In order for the Department to evaluate the extent to which each Applicant proposes to provide, or has provided, health care services for those unable to pay, address each of the following review considerations concerning such financial accessibility by providing written narrative as well as documentation: a. The Applicant should have policies and directives related to the acceptance of financially indigent, medically indigent, Medicaid, PeachCare, and Medicare patients for necessary treatment. Explain how the Applicant meets this requirement. Limit your response to the space provided. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. Townsend Park Health and Rehabilitation, LLC dba Townsend Park Health and Rehabilitation currently operates the existing center and will continue to operate the reconstructed and replaced center. Townsend Park Health and Rehabilitation, LLC dba Townsend Park Health and Rehabilitation currently and will continue to participate in both the Medicare and Medicaid programs. This reconstruction and replacement will not affect the center's participation in these programs. Medicare and Medicaid Benefits policy attached in Appendix J Admission Agreement attached, see section 4.3 in Appendix J 17 Attach the requested policies and directives as APPENDIX J. b. The Applicant should have policies ensuring that medical staff privileges allow a reasonable acceptance of referrals of Medicaid patients, PeachCare patients, and all other patients who are unable to pay all or a portion of their health care costs. Explain how the Applicant meets this requirement. Limit your response to the space provided. Not applicable. The Operator does not provide urgent care services at this location and no emergency referrals are expected. Attach the requested policies and directives as APPENDIX J. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 27 Revised July 2008 c. The Applicant must provide evidence of specific efforts made to provide information to patients regarding arrangements for satisfying incurred health care charges. Explain how the Applicant meets this requirement. Limit your response to the space provided. The Operator employs a Financial Controller who works directly with families to ensure they have adequate information about the center's charges. They assist the patients and families with collection of private insurance funds as appropriate. They refer patients and families to appropriate government agencies for assistance with determination of eligibility for benefits including Medicare eligibility, Medicaid eligibility, US Department of Veterans Affairs benefits, etc. The Operator assists with providing these insurance providers and government agencies with the appropriate documentation from the center to ensure accurate and timely payment for patient benefits. See Pre-Admission Financial Counseling Policy in Appendix J d. The Applicant should, if applicable, have documented records of funds received from the county, city, philanthropic agencies, donations, and any other source of funds (other than from direct operations) for the provision of health care services to indigent, Medicaid, and PeachCare patients. Explain how the Applicant meets this requirement. Limit your response to the space provided. The Operator does not receive funds from the county, city, philanthropic agencies, donations, or any other source of funds for provision of healthcare services to indigent, Medicaid, and PeachCare patients. e. The Applicant should have documented records as evidence of the Applicant's commitment to participate in the Medicaid, Medicare, and PeachCare programs, as well as the Applicant's commitment to provide health care services to all presenters regardless of race, gender, disability, or ability to pay, and the Applicant's commitment to providing charity care. Explain how the Applicant meets this requirement. Limit your response to the space provided. The Operator's participation in the Medicaid program is well documented: Year Medicaid Days Medicare Days Total Days 2013 30,612 3,472 41,241 2012 28,343 4,386 43,447 2011 30,621 4,045 42,347 The Operator's historical performance documents the participation in Medicare and Medicaid. The Operator's project Pro Forma demonstrates the commitment to continue participation in Medicare and Medicaid. The Operator has consistently demonstrated compliance with Title V and VI of the Civil Rights Act as evidenced the most recent letter of compliance from DCH HFR. DCH HFR letter in Appendix J, also see Admission Agreement in section 2.1.5 in Appendix J State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 28 Revised July 2008 f. The Applicant should have documented records as evidence that the levels of health care provided correspond to a reasonable proportion of those persons who are medically indigent and those who are eligible for Medicare, Medicaid or PeachCare within the service area. Attached records of care provided to patients unable to pay should include Medicare and Medicaid adjustments, PeachCare, other indigent care, and other itemized deductions from revenue, including bad debt. Explain how the Applicant meets this requirement. Limit your response to the space provided. The Operator provides the majority of care to Medicare and Medicaid patients. The facility track record for Medicare and Medicaid utilization is detailed on page 29.1 The Operator files a Medicaid cost report each year that specifically details the care provided to patients who are unable to pay for their care. The data found on page 29.2 is pulled directly from cost report data on file with the State of Georgia related to Medicare and Medicaid contractual allowances and Medicare crossover bad debt. Also included is private pay bad debt write offs from the internal accounting records of the Operator. (Medicaid Cost Report Schedule B-1, Medicare Reimbursement Settlement Statement in Appendix J) Providing care to individuals who cannot afford to pay for their care is an integral part of the Operator's mission. Attach any evidence directly supporting your explanation as APPENDIX J. 34. Has the Applicant made any previous indigent and charity care commitments associated with a previous Certificate of Need application? ❑ YES ® NO If YES 4 Complete the following table. Specify the information requested for each applicable facility and/or service. Also, attach sheets to indicate how the amount of the commitment was determined. If NO 4 Continue to the next question. Previous Indigent/Charity Care Commitments Project Date of Percent of Facility/Service Number Approval Adjusted Outcome Gross Revenue % ❑Met ['Not Met % ❑Met ❑Not Met % :Wet ONot Met % ['Met ❑Not Met % ['Met ❑Not Met % ['Met ❑Not Met State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 29 Revised July 2008 Bartow County Holdings, LLC Certificate of Need Historical Case Mix Year 2011 2012 2013 Medicare Days 3472 4386 4045 Medicare % 8.41% 10.09% 9.55% Medicaid Days 30612 28343 30621 Medicaid % 74.22% 65.23% 72.30% Total Patient Days 41,241 43,447 42,347 Page 29.1 Bartow County Holdings, LLC Certificate of Need Payor Source 2011 2012 2013 Medicare Routine Service Revenue 580151 757998 747180 Contractual Allowance - Medicare 411459 356504 276924 Medicaid Routine Service Revenue 5137633 4970432 5648952 Contractual Allowance - Medicaid -483410 -704904 -632039 Medicare Crossover Bad Debt 19281 12981 51365 Private Pay Bad Debt 9754 59322 27756 Page 29.2 35. Is the Applicant making an indigent and charity care commitment for this project? ❑ YES ® NO If YES 4 Complete the information requested below. Note that failure to meet an indigent and charity care commitment could result in fines and constitute grounds for an adverse ruling on a future Certificate of Need application. If NO 4 Continue to the next question. Is the commitment voluntary, or is it required by a specific Certificate of Need rule? ❑ Voluntary ❑ Mandatory Is the commitment service-specific or hospital-wide? ❑ Service-Specific ❑ Hospital-Wide In the space provided below, describe the commitment and include its amount and effective date(s). Indicate what percentage of adjusted gross revenues the commitment represents. Not Applicable State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 30 Revised July 2008 Rule 111-2-2-.09(1)(h): Relationship to Health Care Delivery System The proposed new institutional health service has a positive relationship to the existing health care delivery system in the service area. 36. In the space provided below, explain how the proposed new institutional health service will complement existing services, provide services for which there is a target population, provide an alternative to existing services, or provide services for which there is an unmet need. You may wish to list referral arrangements and working relationships with other providers. NOTE: If your explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 31.1, the second Page 31.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 31.1, etc. behind this Page 31. 17 Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the relationship of your project to the health care delivery system into APPENDIX K. All documents such as tables, charts, and maps that you wish to use to analyze the relationship with the health care delivery system and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. This center has operated as a skilled nursing center under this owner and previous owners for several decades in this current location in this community. It is a fully integrated and critical component of the healthcare delivery system in Bartow County. This reconstruction and replacement will allow it to continue serving patients in this community in an improved environment for many years in the future. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 31 Revised July 2008 Rule 111-2-2-.09(1)(i): Efficient Utilization The proposed new institutional health service encourages more efficient utilization of the health care facility proposing such service. 37. State how your proposed project will enhance delivery of the services within your facility. Do not exceed the space provided for your response. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the effect your project on utilization into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The reconstruction and replacement design will deploy improved technology such as a new nurse call system to improve staff notification of resident needs. The reconstruction and replacement of the therapy space will allow the therapy personnel to deploy new technology to serve the therapeutic needs of patients being served at the center. Reconstructed and replaced dining spaces will allow for more efficient deployment of staff members to enhance the dining program in the center. Rule 111-2-2-.09(1)(j): Non-Resident Services The proposed new institutional health service provides, or would provide, a substantial portion of its services to individuals not residing in its defined service area or the adjacent service area. 38. State how your proposed project provides or will provide a substantial portion of the proposed services to individuals not residing in the defined service area or the adjacent service area. Limit your response to the space provided. If this consideration is not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you wish to use to demonstrate how your project conforms to this rule into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 32 Revised July 2008 Rule 111-2-2-.09(1)(k): Research Projects The proposed new institutional health service conducts biomedical or behavioral research projects or a new service development, which is designed to meet a national, regional, or statewide need. 39. State how your proposed project includes research projects or develops new services that will meet a national, regional, or statewide need. Limit your response to the space provided. If not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you wish to use to demonstrate how your project conforms with this rule on research projects into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. There are no research projects as a part of this plan. Rule 111-2-2-.09(1)(1): Assistance to Health Professional Programs The proposed new institutional health service meets the clinical needs of health professional programs which request assistance. 40. State how your proposed project will meet the clinical needs of health professional programs, which request assistance. Limit your response to the space provided. If not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of how your project addresses the needs of health professional programs into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 33 Revised July 2008 Rule 111-2-2-.09(1)(m): Improvements and Innovation The proposed new institutional health service fosters improvements or innovations in the financing or delivery of health services, promotes health care quality assurance or cost effectiveness, or fosters competition that is shown to result in lower patient costs without a loss in the quality of care. 41. State how your proposed project fosters improvements or innovations in the financing or delivery of health services, promotes health care quality assurance or cost effectiveness, or fosters competition. Limit your response to the space provided. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize to demonstrate your projects compliance with this rule consideration into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. Rule 111-2-2-.09(1)(n): Needs of HMOs The proposed new institutional health service fosters the special needs and circumstances of health maintenance organizations. 42. State how your proposed project fosters the special needs of HMOs. Limit your response to the space provided. If not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the effect of your project on the needs of HMOs into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The Operator will continue to work with HMO's as appropriate to serve the needs of the medical community. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 34 Revised July 2008 Rule 111-2-2-.09(1)(o): Minimum Quality Standards The proposed new institutional health service meets the department's minimum quality Standards, including, but not limited to, standards relating to accreditation, volumes, quality improvements, assurance practices, and utilization review procedures. 43. State how your proposed new institutional health service meets the department's minimum quality standards. Limit your response to the space provided. If not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The reconstructed and replaced center will undergo standard inspections as a regulated healthcare facility in the State of Georgia. Rule 111-2-2-.09(1)(p): Necessary Resources The proposed new institutional health service can obtain the necessary resources, including health care management personnel. 44. State how your proposed new institutional health service meets the department's requirement to be able to obtain the necessary resources. Limit your response to the space provided. If not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. The Operator currently maintains relationships with area healthcare providers, suppliers, and contract professionals as resources in provision of care and services to the patients served in the center. The Operator contracts with Clinical Services, Inc. for provision of support and consultant services. Clinical Services, Inc. personnel assist with ongoing recommendations to the center in provision of care and services to patients served. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 35 Revised July 2008 Rule 111-2-2-.09(1)(q): Underrepresented Health Service The proposed new institutional health service is an underrepresented health service, as determined annually by the department. The department shall, by rule, provide for an advantage to equally qualified applicants that agree to provide an underrepresented service in addition to the services for which the application was originally submitted. 45. State how your proposed new institutional health service meets the department's requirement regarding provision of an underrepresented health service. Limit your response to the space provided. If not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis into APPENDIX L. This is not a proposal for a new institutional health service but is a proposal to reconstruct and replace the existing center in the current location in this community. The proposal is simply to improve the environment and functionality for the patients served in the center. Rule 111-2-2-.09(2): Destination Cancer Hospital 46. State how your proposed new institutional health service meets the department's requirements for a destination cancer hospital under the rule cited above. Include your response in Appendix L. Rule 111-2-2-.09(3): Basic Perinatal Services 47. State how your proposed new institutional health service meets the department's requirements for Basic Perinatal Services under the rule cited above. Include your response in Appendix L. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 36 Revised July 2008 Section 4: Service-Specific Review Considerations 48. The following table documents the service-specific review considerations currently utilized by the Department. a) Carefully review this table and place a checkmark in the box provided for any and all service-specific review considerations that apply to your project. SERVICE-SPECIFIC CONSIDERATIONS Check if Appendix Letter Service Rule Number Applicable See instructions at &Included (d)on next page Short Stay General Hospital Services 111-2-2-.20 ❑ Adult Cardiac Catheterization Services 111-2-2-.21 ❑ w Open Heart Surgical Services 111-2-2-.22 ❑ U▪ Pediatric Cardiac Catheterization and Open Heart 111-2-2-.23 ❑ Services v Perinatal Services 111-2-2-.24 ❑ Freestanding Birthing Center Services 111-2-2-.25 ❑ Psychiatric and Substance Abuse Inpatient 111-2-2-.26 ❑ Services Skilled Nursing and Intermediate Care Facility 111-2-2-.30 ❑ Services cc ▪ Personal Care Home Services 111-2-2-.31 ❑ 2 Home Health Services 111-2-2-.32 ❑ IT Continuing Care Retirement Communities 111-2-2-.33 ❑ C9 z Traumatic Brain Injury Services 111-2-2-.34 ❑ J Comprehensive Inpatient Physical Rehabilitation Services 111-2-2-.35 ❑ cc Ambulatory Surgical Services 111-2-2-.40 ❑ F Positron Emission Tomography Services 111-2-2-.41 ❑ MegaVoltage Radiation Therapy Services/Units 111-2-2-.42 ❑ CONTINUED ON NEXT PAGE State of Georgia:Certificate of Need Application Section 4 Form CON 100 Page-37 Revised July 2008 b) After reviewing the table above and indicating the applicable considerations by placing a check mark in the appropriate rows, obtain a copy of each set of service-specific review considerations that apply to this Certificate of Need application and project. These considerations are available on the Department's website at www.dch.georgia.gov. c) After obtaining the service-specific review considerations, the Applicant should document the project's compliance with each of the applicable rule standards. Attach the applicable considerations to this document. Number the pages of your service-specific considerations starting at Page 38.1, 38.2, etc. and insert them once printed behind this Page 38. If more than one set of service-specific considerations is applicable to your project include them behind this Page starting at Page 38.1 in the order that the considerations appear in the table above. Clearly label each new set of service-specific considerations at the top of page. d) Attach all substantiating documents and supplemental information required by a set of service- specific review considerations in APPENDIX N. If addressing more than one set of service-specific considerations place the substantiating documents in response to the first set of service-specific considerations in APPENDIX N, documents relating to the second set in APPENDIX 0, and so forth until each applicable set of service-specific considerations has its own appendix for substantiating documents and supplemental information. Enter the corresponding letter in the Appendix Letter column in the table on the previous page. Within each Appendix, place the documents and supplemental information in the order in which such items are asked for in the applicable service- specific review standards. NOTE: The Appendices described in (d) above should only be utilized for substantiating documents and supplemental information required by the service-specific review considerations that cannot be reproduced or created as an MS Word document, e.g. QA Policies, Referral Agreements, etc. All documents such as tables, charts, and maps that you wish to use to utilize in your analysis of particular service-specific review considerations that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in (c) above. THE REMAINDER OF THIS PAGE LEFT BLANK. State of Georgia:Certificate of Need Application Section 4 Form CON 100 Page-38 Revised July 2008 CERTIFICATION OF APPLICANT By signing below, a) I hereby certify that the contained statements and all addenda, appendices, or attachments hereto are true and complete to the best of my knowledge and belief and that I possess the authority to submit this application and bind the Applicant to promises made herein; b) I understand that a representative of the Certificate of Need Program may make a direct request of me for additional information in order to deem this application complete; c) I further understand that if awarded a Certificate of Need, information must be provided to the Certificate of Need Program regarding the progress, scope, and costs associated with the project. Consequently, I agree and certify that the Applicant will submit progress reports as required by Rule 111-2-2-.04(2), which specifies the frequency and the content of the progress reports. I understand that failure to comply with these reporting requirements may result in penalties, up to and including revocation of the Certificate of Need; d) I further understand that if issued a Certificate of Need, the Applicant is bound to any representations that have been made within this application and any and all supplemental information; and e) I certify that the Applicant will accept a condition or conditions on the award of a Certificate of Need based upon any representation of intent contained herein. APPLICANT CERTIFICATION Signature ofAuthorized Signatory� (BLUE INK ONLY): N Name: a esa iv, mn4 Title: ?resicf e,ry Date: /0/3/20/ / j/ State of Georgia:Certificate of Need Application Applicant Certification Form CON 100 Page 39 Revised July 2008