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HomeMy WebLinkAboutCON2006131 Intrepid USA Healthcare Services I SSDRa 1 GEORGIA DlPARTMEN:r Of' COMMUNITY HtALnl Georgia MASTER IF~LIE Certificate of Need Application tf~ -'-. FOR DIVISION OF HEAL TH PLANNING USE ONL Y PROJECT NUMBER DATE STAMP ~~ -r';--ruo' f\\{"w r'-; In c 'I' '" -. ~-' , l~ ~ i 1\ ---., ii' , I GA ill! NOV I " 1 ? CI~O^ ! I :." J 20 0 6 .. 1 3 1 JlI 0 0, 0 i:-> -.J . DIVISlor~ OF HEALTH PLANNiNG 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.qeorQia.Qov. 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 Monev 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: F.C. of Georgia, Inc. dlbla Intrepid USA Healthcare Services . 1- Have you submitted an original signed in blue ink and provided one (1) copy of c><'J Yes this signed application? DNo 2. Enter Total Cost Applicable to Filing Fee (From Line 16, Question 22, Page 13) D-.I~1! $ '^~' ,_.~'"',. 3. Calculate the Filing Fee and Total Amount Due (Check one of the following and enter the amount in the column to the right) D Line 2 is between 0 to $1 million -+ Enter $1 ,000.00 D Line 2 is between $1 million and $50 million -+ Enter Line 2 x .001 $1,000.00 D Line 2 is greater than $50 million -+ Enter $50,000.00 4. Have you submitted a Certified Check or Money Order made payable to "State c><'JYes of Georgia" for the amount listed in Line 3 above? DNo Submit to: Division of Health Planning Department of Community Health 2 Peachtree Street, NW - 5th Floor Atlanta, GA 30303 'l: '" ':.: r::C .J '" o o o 'l: ... ~ ~. GEORGIA DEPARTMENT OF &)}. COMMUNITY HEALTH AcknowledQement of Home Health Application Submission Applicant: Intrepid USA Healthcare Services d/b/a Intrepid USA Home Health Services SSDR: 8 Date Submitted: 11/13/2006 Time Submitted: (L\ '. 3 \ . ReooNed b~ ~ Inru", GPM This letter acknowledges that you have submitted a home health application in accordance with the home health batching notice and the rules of the Department of Community Health, This letter only acknowledges the submission of the application with a valid form of payment in the correct amount. This letter does not indicate that the application is complete for review. The Department will post a notice of completeness on its website by 5:00 pm today, This notice will acknowledge the applications that were received and will contain information on whether the application was deemed to be complete or incomplete. ,: . , . . . . . . . . .REESE&HOPKJ[NS,LLC , ATTORNEYS AT LAW ' October 13, 2006,2006 DIVISION'oHIEAH " CLYDE L. REESE III,Esq, ,.' , creese@reesehopkinslow,r;om . . Robert M. Rozier, Esq~ Executive Directclr Division of Health Plarming Georgia Department of Community Health 2 Peachtree St;5thFloor . '.' ' . . . , Atlanta, GA 30303-3142 . 1'~ ',': .,:, ,.,'" ,I", . HAND DELIVERY' ...." .,. ',. J " ~. , ";~ . " '~ " > .," .' '. RE:,' ,', ....., ."' , , . ",', Dear Mr. Rozier: . " ' ~ . '.' . . . ,. , , . . , . . - "., '. .' This fi~ represents Intrepid USA Healthcare Services d/b/a Intrepid USA. Home Health, Services (Intrepid USA). Please accept this letter as the applicant's official Letter of' Intent to applyin State Service Delivery Region (SSDR)8 fora riew home,health agericy' (HHA).pursuant to the Batching Review Cycle 'Notification for Home Health Services . issued on September 14,2006, . . .... ,', -,." Sincerely, ~k'.:-J-e~ Clyde L Reese, III , ./ / y-------. , Cc: . Hal Sims . Newell D.\' arborough ' .,. '., ' . 84 Peachtree Si., NW. Suite 600.'Flatiro'l'\ 8Idg.... Atlp"taiGeorgia 30303 404.658-6088. Fax404'658'6089 '.' .. ""'.; '!.. . '. "..-. ".-" 'YARBOROUGH . .' . ' . ". '", , Cbnsultir:ig,lnc.' )(1."\ ~l.\Rsill.:n(.F. L.\1'\E S\\:\;,\;N,\] I. GEOR(jIA JI.hi) . <Jll92S:SIl<}(, (f) q12-'llS~Ol07 . c-m~il: t\IH"@t\Or,COM ,.." n,., ,. '""" November 8,2006 ViaHahJDelivelY , t." MrRobertM.R.ozier, 10,. MHA.' Executive Director"' . Divi'sion of Health Planning . Dep'artinentol' Conimtinity Health 2 Peachtree. Street, NW _5'h Floor: ' Atla~ta, Georgia' 30303, ..' .. " RE:,Intrepidt}SA Healtheare Services, Home Health CON Application, Ne~ Agency, SSDR 8 . '. .-" . . -- . " .',.' - " .' '. -"', . . I . " '- bea~ l\1r: Rozicc; ';" ',' .',- J" " .. '-. ", ." . -' ; .'. ",-' .. Ene!osed please find a signed original and one eopyoftheab?ve~refereneedCONap"lieation along with a,certified, check in.the amount of$I,OOO.OO payable tO,the State of Georgia for the filing fee. " .: '., . .r:':, . . . '" " ...... . "1 ... " . , , 'Thariic y;iufor your attention to this matter. Please do not hesitate to, eon't~ctmeif you'or your staff h~ve questions qrheed additiomil inforrrl~tion;' .' : . . . . ,-. " , ' ' , '.', ", .... "." .......~.,..:,... ,\. '., '-'-' -;,' ," . 'j.:' .;J ~ >~I). . . .' '.' .', ..,'-: , Ne",ell D. Yarborough, Jr. President - -, 1._. .t. '" .,,," cc: ' client, '. ~ , 'Clyd~ Reese, Esq: '. :-- '../ '.' . ! ~ .-,'. "e ',' . ",- - .~.' . .~.. ' Intrepid USA Healthcare Seroices Certificate of Need Application Medicare Certified Home Health Services Nell' A,gewy: 5:\'Df( H 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 Location Copy of Licenses/Permits (for existing facilities) Question 3, Page 1 & fD Attached at APPENDIX B Question 8, Page 3-4 & 0 Attached at APPENDIX C Question 13, Page 6 Question 17, Page 8 & 0 Attached at APPENDIX D Question 18, Page 9 Questions 22, Page 13 Question 22, Page 13 & 0 Attached at APPENDIX G Question 23, Page 14 & n Attached at APPENDIX G Question 24, Page 14 & 0 Attached at APPENDIX G Question 25, Pages 15-19 Question 32, Page 26 & IC7 Attached at APPENDIX I Question 32, Page 26 & 0 Attached at APPENDIX I Authorization to Conduct Business Lobbyist Disclosure Documentalion of Site Entitlement Detailed Description of the Proposed Project Financial Program Equipment Purchase Orders/Invoices Proof of Necessary Financing Financial Statements Financial Pro Forma Architect Cost Estimates (Certified within 60 days) Schematic Plans All Applicable Service-Specific Review Considerations Question 43, Page 35 et seq. & 0 Attached at APPENDIX N etc. Signature on Original (In Blue Ink) Page 37 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. c-l Attach such proof at APPENDIX A. Have you submitted one (1) original signed application and one (1) copy of said application? The copy must include a copy of the signature at Page 37. Have you included the appropriate filing fee as calculated and reported on the cover page of this 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 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 reporting is due? . Has the Applicant and any and all affiliate organizations satisfied previous indigent and charity care commitments? Has the Applicant satisfied any and all fines, if any, which have been levied by the Department for violation of the Certificate of Need Rules or Statute? State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 C heck if Check Included ifN/A IS! D IS! ISI ISI ISI ISI D ISI ISI ISI D ISI D ISI ISI D ISI D :;z;;:'~;ifr_"n!;ii ISI YES DNO ISI YES DNO ISI YES DNO ISI YES DNO ISI YES DNO ISI YES DNO ISI YES DNO Completeness Checklist Page ii 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.aeorQia.Qov. 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: o Emphasizes instances where supporting documentation is requested and required to be attached into an Appendix; and r:tr 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 % 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 a discretionarily expedited 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 expedited review should be granted. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Instructions Page iji 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. 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 LicenseslPermits 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 L Programs, Improvements and Innovation, and Needs of HMOs Letters of Support M Required Documentation for Service-Specific Review Considerations N,O. etc. (See Page 35 and 36 for Explanation) c:iF 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 Form CON 100 Revised September 2006 Instructions Page iv OVERVIEW OF REVIEW PROCESS (not applicable to Home Health or Nursing Home Batching) 1. After the Department accepts an application, the Department has 10 business days to deem the application complete for the 90-day regular review period. The Department or the Applicant may request a 30-day extension of the regular review period to the maximum 120-day review. Under no circumstances will a review extend past 120 days. An expedited 45-day review may be requested for certain exemptions. 2. If the Department deems an application incomplete, the Applicant has 2 calendar months to provide the necessary information to render the application complete. Otherwise, the application is deemed withdrawn by the Department after 2 calendar months have lapsed. 3. The Department's review of an application is predicated upon the documents and information provided by the Applicant, which may be amended and supplemented during the review period. 4. If a project application is predicated on the Department's need methodology for any service or facility, the need is established as published by the Department on the day the application is deemed complete for review. 5. All letters of opposition for any project application must be completed on the Department's supplemental form and must be submitted on or before the 60lh day to preserve a competing healthcare facility's right to appeal the Department's decision to approve or deny the project application, if that facility is not the Applicant facility or a joined Applicant facility. If the opposition supplemental form is not received on or before the 60'h day, the document will be returned to the submitting party and it will not become a part of the project master file. 6. 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. 7. The Department will schedule a 60-day meeting with an Applicant if the potential exists for denial of a project application. The meeting is scheduied to discuss problems inherent in the application and to provide the Applicant an opportunity to correct through amendment or additional information any deficiencies in the application. 8. The Department will notify the Applicant at the 60-day meeting, if at all possible, or by phone, if a 60-day meeting is not held, whether opposition to the project has been received. If the Applicant wishes to respond to such opposition, if any, the Applicant must do so before the 75'h day of the review cycle. 9. An Applicant may supply additional information and/or amend their project during the review cycle. An Applicant wishing to supply additional information must do so by the 751h day of the review cycle. An Applicant wishing to amend their project must do so at least 10 days before the end of the review cycle. Both additional information and amendments must be submitted attached to the Department's specific form for such purposes. An amendment that increases the project's estimated costs must be submitted with an additional filing fee. 10. An application may be voluntarily withdrawn by an Applicant, and in doing so, gives the Applicant the right to re-submit the same or similar application immediately thereafter. Alternatively, if an application is denied, an Applicant may not re-submit the same or substantially the same application until after 120 days have lapsed. 11. A weekly Tracking and Appeals Report is published by the Department, which details CON events for the previous week. The report includes pending, approved, denied, withdrawn and newly submitted applications; appealed projects, and other requested determinations by the Department. The report is updated and made available at the Department's website, www.dch.qeorqia.qovevery Monday. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Review Process Page v 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 Legai Name: F. C. of Georgia, Inc. d/b/a (if applicable): Intrepid USA Heallhcare Services (Intrepid USA) Address: 6600 Frances Avenue South, Suite 510 City: Edina State: MN I Zip: 55435 County: Hennepin Main Business Phone: 952-285- 7300 Parent Organization: CONTACT PERSON Name: Newell D. Yarborough, Jr. I Title or Position: Consultant Phone: 912-925-5896 I Fax: 912-925-0107 E-mail Address: NDY@AOL.COM 2. Is the name of the facility or proposed facility different than the Applicant's legai name? IZI YES 0 NO If YES -+ 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 -+ Continue to the next question. FACILITY Facility Name: Intrepid USA Healthcare Services Facility Address: 1610-D East Forsyth Street (For initial verification of site only) City: Americus I State: GA I Zip: 31709 County: Sumter I Phone: 229-430-8878 3. If the facility is currently existing, is it currently licensed or permitted by the Department of Human Resources? IZI YES 0 NO 0 Not Applicable If YES -+ 0 Attach a copy of any and all licenses and permits at APPENDIX B. If NO -+ Continue to the next question. If Not Applicable -+ Check one of the following: o Not Currently Existing (Proposed Oniy) o No License or Permit Required State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 1 4. Is the legal owner of the facility different than the Applicant? 0 YES [8] NO If YES -+ 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 -+ Continue to the next question. OWNER #1 Name: Address: City: I State: I Zip: Phone: OWNER #2 Name: Address: City: . I State: . I Zip: Phone: OWNER #3 Name: Address: City: I State: I Zip: Phone: 5. Check the appropriate box to indicate the type of ownership of the Facility. Check only one box. I- Q. o Not-for-Profit Corporation =- w X w ~ o Pubiic (Hospital Authority or Government) l- e> o General Partnership [8] Business Corporation o Sole Proprietor Z ~ Q. X o limited liability Partnership o Limited Liability Corporation ~ State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 2 . 6. Will the entire facility be operated by an entity other than the Applicant or the legal owner? DYES IZI NO If YES-+ Identify the operator and include the complete name, address, and telephone number. If NO -+ Continue to Question 8. OPERATOR Name: . . Address: City: I State: I Zip: Phone: 7. Check the appropriate box to indicate the type of operator. Check only one box. I- o Not-for-Profit Corporation l1. :;; W >< W ~ o Public (Hospital Authority or Government) . Cl o General Partnership o Business Corporation o Sole Proprietor Z ~ l1. ~ o Limited Liability Partnership 0 Limited Liability Corporation 8. Please provide documentation of the organizational and legal structure of the Applicant as indicated in the table below. E7 Attach this documentation as APPENDIX C. Please attach the documents in the order they are listed. ORGANIZATIONAL STRUCTURE o Name of Each Officer and Director o Articles of Incorporation Not-for-Profit o Certificate of Existence Corporation o Bylaws o Organizational Chart(s) o Application/Authorization to do Business in Georgia (for Non-Resident Corporations) Public o All Governing Authority Approvals for this Application and Project (Hospital Authority o Bylaws or Government) o Organizational Chart(s) State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 3 ORGANIZATIONAL STRUCTURE o County and Municipal Government Business Authorization Documents Sole Proprietor (e.g. Licenses, Permits, Etc.) o Bylaws o Organizational Chart(s) o Name, Partnership Interest, and Percentage Ownership of Each Partner o Partnership Agreement General Partnership o Certificate of Existence o Bylaws o Organizational Chart(s) . o Name, Partnership Interest, and Percentage Ownership of Each Partner o Partnership Agreement Limited Liability o Certificate of Existence o Certificate of Registration Paqnership o Articles of Organization o Bylaws o Organizational Chart(s) [8J Name of Each Officer and Director [8J Articles of Incorporation Business [8J Certificate of Existence Corporation [8J Bylaws [8J Organizational Chart(s) [8J Application/Authorization to do Business in Georgia (for Non-Resident Corporations) o Name of Each Officer and Director o Articles of Incorporation o Operating Agreement Limited Liability o Certificate of Existence . Corporation o Bylaws o Organizational Chart(s) o 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. c]fF NOTE: Do not exceed the allotted space for your response. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 4 10. Does the Applicant have Legal Counsel to whom legal questions regarding this application may be addressed? [gJ YES 0 NO If YES -+ Identify the lead attorney below. If NO -+ Continue to the next question. LEGAL COUNSEL Name: Clyde L. Reese, III Firm: Reese & Hopkins, LLC Address: 84 Peachtree St., NW, Suite 600 City: Atlanta I State: GA I Zip: 30303 Phone: 404-658-6088 I Fax: 404-658-6089 Email: CReese@reesehopkinslaw.com 11. Did a Consultant prepare and/or provide information in this application? If YES -+ Identify the Consultant below. If NO -+ Continue to the next question. [gJ YES D NO CONSULTANT Name: Newell D. Yarborough, Jr. Firm: Yarborough Consulting, Inc. Address: 103 Marsh Edge Lane City: Savannah T State: GA I Zip: 31419 Phone: 912-925-5896 I Fax: 912-925-0107 . Email: NDY@AOL.COM 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? DYES [gJ NO If YES -+ 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 -+ Continue to the next question. State of Georgia; Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 5 AUTHORIZED REPRESENTATIVE Name: Firm: Address: City: I State: I Zip: Phone: T Fax: Email: rJfr 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? DYES [2:J NO If YES -+ 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 11 M -2- .03(2) require such registration. If NO -+ Continue to the next question. LOBBYIST DISCLOSURE STATEMENT Affiliation with Registered with Name of Lobbyist Applicant State Ethics Commission? D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 6 Section 2: Project Description 14. Indicate the type of facility that will be involved in the project. FACILITY TYPE 0 Birthing Center 0 Hospital 0 Continuing Care Retirement Community (CCRC) 0 Nursing or Intermediate Care Facility 0 Freestanding Ambulatory Surgery Center 0 Personal Care Home 0 Home Health Agency 0 Traumatic Brain Injury Facility 0 Diagnostic, Treatment or Rehabilitation Center (DTRC) o Freestanding Single-Modality Imaging Center 0 Freestanding Multi-Modality Imaging Center o Mobile Imaging 0 Practice-Based Imaging o Other: 15. Indicate the services that will be involved or affected by this project. SERVICES Hospital Inpatient Diagnostic Services o Medical/Surgical ~.. o Computerized Tomography (CT) Scanner o Open Heart Surgery o Magnetic Resonance Imaging (MRI) OPed iatric o Positron Emission Tomography (PET) o Obstetrics o Diagnostic Center, Cancer/Specialty o ICU/CCU o Newborn,ICU/INT Other Outpatient Services o Newborn/Nursery o Ambulatory Surgery W I- o Rehabilitation o Birthing Center ::::l U o Acute, Burn, Other Specialty <I: Clinical/Surgical o Long Term Acute Care o I npatient, Other o Emergency Medical o Psychiatric, Adult o Emergency Medical, Trauma Center o Substance Abuse, Adult o Adult Cardiac Catheterization 0 Psychiatric, Child/Adolescent o Gamma Knife 0 Substance Abuse, Child/Adolescent 0 Lithotripsy 0 Psychiatric, Extended Care 0 Pediatric Cardiac Catheterization 0 Radiation Therapy 0 ::i: 0 Skilled Nursing Care 0 Personal Care Home Cl z a: 0 Intermediate Nursing Care 0 Traumatic Brain Injury (TBI) 0 w ....J I- 0 Continuing Care Retirement Community (CCRC) 0 Home Health a: 0 Administrative Support o Grounds/Parking W :I: 0 Non-Patient Care, Other o Medical Office Building I- 0 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 2 Page 7 16. Check the most appropriate category(ies) for this project. Check all that apply. PROJECT CATEGORY Construction Service Change D New Facility ISI New Service D Expansion of Existing Facility D Expansion of Service D Renovation of Existing Facility D Expansion or Acquisition of Service Area D Replacement of Existing Facility D Consolidation of Service D Relocation of Facility Procurement of Medical Equipment D Other D Purchase D Lease D 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. D Attach the appropriate documents that provide for the Applicant's entitlement to the site at APPENDIX D. Ci'F 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: 1610-0 East Forsyth Street City: Americus T County: Sumter I Zip: 31709 Number of Acres: NA Status of Site Acquisition o Purchased (attach deed) o Leased (attach lease) o Under Option (attach option agreement) o Under Contract (attach contract or bill of sale) [8J Other; please specify: Office spaced will be leased if the CON is approved Zoning Is the site appropriately zoned to permit its use for the purpose stated within the application? [8J YES DNa If NO .. 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. su~h as mortgages, liens, DYES assessments, easements, rights-af-way, building restrictions, or flood plains? [8J NO State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 2 Page 8 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. W NOTE: If your description exceeds this blocked space, attach additional 8- Yo 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. "Intrepid" is an established provider of Medicare certified home health services in Georgia. Intrepid is applying to establish a new agency in SSDR 8 that will serve the following counties: Challahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, and Taylor. Collectively the need in these counties is 702 patients which exceeds the minimum of 500 patients required to establish a new agency. A full range of Medicare certified home health services will be provided including Skilled Nursing, Physical Therapy, Speech Therapy, Medical Social Services, and Home Health Aides to all patients in need including the indigent population. In addition to the standard home health services, Intrepid currently has the following Clinical specialty programs: Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, CVA/Stroke Management, Hypertension, Myocardial Infarction, Asthma, Pneumonia, Wound Care, and Rehabilitation/Restorative Care. Furthermore, the following additional clinical specialty programs are planned for implementation during 2007: Deep Vein Thrombosis, Amyotrophic Lateral Sclerosis, Parkinson's Disease, Fall Risk/Prevention Program, Peripheral Vascular Disease, PalliativelTerminallEnd- of-Life Care, and Pre-op Orthopaedic Services Program. CHAP accreditation will be sought if the application is approved. Intrepid plans to comply with all Georgia rules and regulations as well as the Medicare Conditions of Participation. Intrepid formally commits to a indigent/charity care level of 3% of Adjusted Gross Revenues. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 2 Page 9 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. Aiso explain how the application is consistent with the Applicant's own long range plans. r::tF NOTE: /fyour explanation exceeds this blocked space, attach additiona/8.Y, 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. State Health Plan (Home Health Component Plan): IA. GOAL: To ensure that Georgia citizens have access to cost-effective, efficient, and quality home health services. B.OBJECTIVES 1. Improve access to cost.effective, quality home health services by authorizing these services based on a demand.based numerical need methodology. 2. Ensure quality and patient safety through compliance with appropriate standards and guidelines. 3. Assess availability, quality, and effectiveness of services being provided through information and statistical data. 4. Encourage continuity of Home Health Services. 5. Improve access to Home Health Services by encouraging the provision of services on a non. discriminatory basis. 6. Improve financial access to Home Heaith Services by encouraging the provision of services to indigent and charity patients and participation in public reimbursement programs. RESPONSE; The application was filed in response to the published need (Objective B1). The applicant plans to become CHAP accredited (Objective B2). The applicant plans to participate in OASIS (Outcome and Assessment Information Set) and OBQM/OBQI (Outcome Based Quality Management/Improvement) (Objective B3). Community linkages will be established to ensure continuity of care (Objective B4). All patients in need (regardless of payor source), including indigent/charity patients will be served (Objectives B5 and B6). Applicant's Long Range Plan:To expand into all appropriate markets of opportunity. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 10 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; . Indude maps that dearly 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 slle to patients/clients, visitors, and employees; and . For services that already have documented utilization rates, indude such historical utilization data, and projections for future utilization. <:iF 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. o 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. The need for this project was based upon the "Certificate of Need Balching Review Cycle Notification for Home Health Agencies" dated September 14, 2006. Public transportation is not an issue for HHAs since caregivers travel to patients. All visiting staff use their own personal vehicles and the proposed office (AmericuslSumter County) is located in a relatively large citiy, so employee access is also not an issue. HARRIS (proposed) Georgia SSDR 8 Intrepid USA Proposed New Agency Proposed Counties: All Counties With Need DOOLY &"mYART (p<<opooed' was_ SUMTER ,........., CRISP 25mi.. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Seclion 3 Page 11 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. rJr NOTE: If your explanation exceeds this blocked space, attach additional B-Y, 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. rc'J 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. SS DR 8 8 8 10 8 8 B B 1 B 4 10 6 6 B B 6 11 6 10 10 3 fl ag HHA County County Servedl Home Health Agency 2005 Pts 2005 MS 5,519 1,387 1,580 865 494 392 o 133 192 o 359 55 19 11 o o 10 16 o 3 1 o 2 100.0 25.1 28.6 15.7 9.0 7.1 0.0 2.4 3.5 0.0 6.5 1.0 0.3 0.2 0.0 0.0 0.2 0.3 0.0 0.1 0.0 0.0 0.0 + + + SSDR B RESIDENTS Muscogee Chattahoochee Valley HH Muscogee CareSouth HH MU5cogee Crisp VNA Cordele Dougherty Phoebe Home Care Albany Crisp CareSouth Cordele/CrispHosp Harris Home Care 8t Francis(mrg) Muscogee Muscogee Home Health Muscogee Access HH Columbus (cis) Catoasa North Georgia HH/Amedisys Muscogee Ultra Care Georgia Troup West Georgia Home Care Decatur VNA Southwest Georgia Bibb Central Georgia HH Macon Houston Preferred HH Warren Robins Randolph VNA ClayIQuitmIRand(mrg) Harris Lanier Home Health Bibb Amedisys HH Macon Tift VNA Greater Tift Bibb Pediatric America Bibb Calhoun Englewood Health Arlington Mitchell Englewood Health Camilla Cherokee Community Home Health All home health agencies essentially serve the same population groups, primarily the 65+ population. While the other agencies in SSDR 8 undoubtedly provide high quality care (and vary in their clinical offerings), there is no public data on the clinical specialty programs offered by existing home health agencies. + + + + + + + The application was filed in response to the need identified by DCH. Therefore, the approval of this application will, therefore, will enhance the existing health service delivery system in SSDR 8. While there were no internal organizational alternatives considered, Intrepid did perform an internal market assessment of each new county proposed to be served before deciding to proceed with this CON application. State of Georgia: Certificate of Need Application Form CON 100 ' Revised September 2006 Section 3 Page 12 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 dol/ar amounts except Cost / Sq. Ft. PROJECT COST ESTIMATES Type of Cost Amount Sq. Ft. Cost I Sq. Ft. COSTS APPLICABLE TO FILING FEE Construction (1) New Facility Costs (2) Expansion Costs (3) Renovation Costs (4) Architectural and Engineering Fees (5) Subtotal Construction 0.00 Equipment (6) Fixed E quipment (not in construction contract) (7) Movea Ie Equipment (8) Subtotal Equipment 0.00 Other (9) Contingency (10) Legal and Administrative Fees (11) Interim Financing . (12) Underwriting Costs (13) Building and Fire Code Compliance . (14) Other: Start-up Costs 50,000.00 (15) Subtotal Other 50,000.00 (16) TOTAL COST APPLICABLE TO FILING FEE 50,000.00 COSTS EXCLUDED FROM FILING FEE (17) Site Acquisition Cost (18) Predevelopment Costs (a) Preparation of Site (b) Development and Preparation of CON Application 20,000.00 (19) Subtotal Predevelopment 20,000.00 (20) Escrow for Debt Service (21) TOTAL COST EXCLUDED FROM FILING FEE 20,000.00 (22) GRAND TOTAL ESTIMATED PROJECT COST 70,000.00 qr NOTE: Use the amount of Line 22 for atl responses throughout this application except for calculating the filing fee. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 13 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. 0 Attach documentation indicating the current availability of grants, private contributions, and unrestricted reserves, if any, at Appendix G. Fund Sources Source Amount DEBT (1) Revenue Certificates (2) General Obligation B nds (3) Commercial Loans (4) Government Loans EQUITY (5) Grants (6) Private Contributions (Philanthropy) (7) Public Campaign (8) Unrestricted Reserves on Hand 70,000.00 (Cash) (9) Other (please specify): (10) TOTAL ESTIMATED FUNDS 70,000.00 qr 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? 0 YES [SJ NO If YES -+ Ie? Attach the most recent financial audit at APPENDIX G. If NO -+ Please provide Balance Sheets, Bank Statements, Tax Returns, or other financial statements verifying income. 0 Attach this documentation in APPENDIX G. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 14 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 (mm/yy) Period Covered (Month and Year) 07/2007 to 06/2008 07/2008 to 06/2009 (1) Number of 527 702 Beds/Rooms/Proced u res/Patients (2) Projected Percent Occupied or Utilized 75.00 % 100.00 % REVENUES (3) Inpatient Revenues 0.00 0.00 (4) Outpatient Revenues 1,585,161.00 2,176,685.00 (5) Patient Revenues 1,585,161.00 2,176,685.00 (6) Other Revenues 0.00 0.00 (7) GROSS REVENUES 1,585,161.00 2,176,685.00 Deductions From Revenues (8) Indigent and Charity Care 45,768.00 61,944.00 (9) Bad Debt 6,649.00 9,123.00 (10) Contractual Adjustments Medicaid 41,332.00 59,067.00 Medicare 99,350.00 185,271.00 Other 13,299.00 18,246.00 (11) Other Free Care (12) TOTAL DEDUCTIONS 206,398.00 333,651.00 (13) NET REVENUES 1,378,763.00 1,843,034.00 EXPENSES Direct Expenses (14) Salaries and Benefits 691,212.00 919,291.00 (15) Supplies 20,046.00 27,484.00 (16) Other 28,929.00 39,348.00 (17) DIRECT EXPENSES 740,187.00 986,123.00 Indirect Expenses (18) Depreciation 204.00 276.00 (19) Amortization 14,000.00 14,000.00 (20) Interest State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 15 Pro Forma Income and Expense Projections Type of Income or Expense First Year (mm/yy) Second Year (mm/yy) Period Covered (Month and Year) 07/2007 to 06/2008 07/2008 to 06/2009 (21) Other 255,847.00 344,833.00 (22) INDIRECT EXPENSES 2,700,951,00 359,109.00 (23) TOTAL EXPENSES 1,010,238.00 1,345,232.00 INCOME / (LOSS) (24) Income I (Loss) 368,525.00 497,802.00 (25) Income Taxes 126,036.00 170,248.00 (26) NET INCOME I (LOSS) 242,089.00 327,554.00 GROSS PATIENT REVENUE BY SOURCE Government (27) Medicare 1,317,896.00 1,809,749.00 (28) Medicaid 88,513.00 122,534.00 (29) Other Government (30) Government 1,406,409.00 1,932,283.00 Nongovernmental (31) Third Party Payors 178,752.00 244,402.00 (32) Self-Pay (33) Other Nongovernmental (34) Nongovernmental 136,540.00 244,402.00 (35) TOTAL, ALL SOURCES 1,585,161.00 2,176,685.00 ~ cJr NOTE: These amounts must equal "Patient Revenues" under line 5 on Page 15 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 16 Briefly outline the assumptions made for each line item of statistics entered in the Pro Forma Income and E P . f b XDense rOlec Ions a ove. PRO FORMA ASSUMPTIONS (1) Number of Beds/Rooms/Procedures/Patients: Total need equals 702 Patients. 2007/2008 = 527, 2008/2009 = 702. (2) Projected Percent Occupied or Utilized: 2007/2008 = 75%, 2008/2009 = 100% of Need Utilized. (3) Inpatient Revenues: NIA (4) Outpatient Revenues: Charges uniformly applied to all payer sources on a per visit basis. Year 2 (2008/2009) Charges increased by 3%. See Pro Forma Assumptions for detailed Charge amounts. (6) Other Revenues: N/A (8) Indigent and Charity Care: Charges uniformly applied to all payer sources on a per visit basis. Year 2 (2008/2009) Charges increased by 3%. See Pro Forma Assumptions for detailed Charge amounts. (9) Bad Debt: Bad debts estimated at 5% of Commeciallnsurance/Private pay Gross Charges. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 17 PRO FORMA ASSUMPTIONS (10) Contractual Adjustments: . Medicare equals difference between Gross Charges and Average PPS Payment Rate for 2005 per 12/31/2005 Medicare Cost Report for the Albany Agency. Medicaid equals difference between Cost and Charges. Commercial Insurance equals 10% of Gross Charges and Bad Debts. Indigent Care equals approximately 3% of Gross Charges. (11) Other Free Care: N/A (14) Salaries and Benefits: Salaries and Wages based upon 12/31/2005 Medicare Cost Report for Albany, Georgia Agency. Benefits estimated at 16.87% of Wages. See Pro Forma Assumptions for Detail Salary and Wage amounts. (15) Supplies: Supplies Revenues estimated at 8.75 per SN Visit. Supplies Expense eatimated at 50% of Supply Charges. (16) Other: Travel Expense based upon 12/31/2005 Medicare Cost Report for the Albany, Georgia Agency. (18) Depreciation: Depreciation based upon 12/31/2005 Medicare Cost Report for the Albany, Georgia Agency. (19) Amortization: Based upon 20,000.00 related to the CON and 50,000 related to Start-up type costs, amortized over 5 years. (20) Interest: No interest expense oroiected. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 18 PRO FORMA ASSUMPTIONS (21) Other Indirect Expense: Based based upon 12/31/2005 Medicare Cost Report for the Albany, Georgia Agency. (25) Income Taxes: Federal Income Taxes estimated at 30% of Net Income. State Income Taxes estimated at 6% of Net Income. (27) Medicare: Utilization based upon Georgia HHA Survey 2005 Data for SSDR 8. (28) Medicaid: Utilization based upon Georgia HHA Survey 2005 Data for SSDR 8 (29) Other Government: Included in Third Party Payors. (31) Third Party Payors: Utilization based upon Georgia HHA Survey 2005 Data for SSDR 8. (32) Self-Pay: Included in Third Party Payors. (33) Other Nongovernmental: Indigent estimated at 3% of Gross Charges. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 19 26. Provide details of the Applicant's total existing indebtedness in the following table: Associated lender Name Origination Due Date Outstanding Interest Capital Project Date Principal Rate CON/lNR # (if applicable) NA % % % % % % % % % % % % % % % % % % % % Slate of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 20 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 0.00 4.69 4.69 Licensed Practical Nurse Licensed Nurse Practitioner or Other Advanced Practice Nurse Nurse Midwife Nursing Assistant Physician Pharmacist Dentist Social Worker 0.00 0.15 0.15 Certified Addiction Counselor Audiologist Radiological Technician Surgical Technician . Physical Therapist 0.00 2.83 2.83 Respiratory Therapist Occupational Therapist 0.00 0.45 0.45 Psychologist Speech - Language Pathologist 0.00 0.10 0.10 Medical Laboratory Technologist Personal Care Aide Home Health Aide 0.00 1.85 1.85 Total Other Staff 0.00 9.04 9.04 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 21 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. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 22 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 nroiected 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 andlor operated by the Applicant, if applicable. (jff" 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. E7 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. Please note, however, that as of October 1999, the Center for Medicaid and Medicare Services (CMS) issued proposed regulations for a Prospective Payment System which became effective for all Medicare- certified home health agencies on October 1, 2000. The regulations establish payments based upon episodes of care. An episode is defined as a length of care up to 60 days with mutiple continous episodes allowed under this rule. Episode payments are made to providers regardless of the costs or charges to provide care which effectively renders existing charges moot. Proposed charges by discipline for Intrepid are as follows: Year 1 2007/2008: SN = 165.00, PT, OT, ST, MSW = 185.00, HHA = 90.00 & Medical Supplies = 8.75 per Visit. Year 2 200812009: SN = 169.95, PT, OT, ST, MSW = 190.55, HHA = 92.70 & Medical Supplies = 9.01 per Visit. Average Gross Charge Per Visit 2007/2008 = $162.21, Average Net Charge Per Visit 2007/2008 = $141.09 Average Gross Charge Per Visit 2008/2009 = $167.09, Average Net Charge Per Visit 2008/2009 = $141.48 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 23 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: NA (there is no constuction associated with this project) Firm: Address: City: I State: I Zip: Phone: . Registration Number: 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 2. Plans approved by State Architect 3. Enforceable Construction Contract Signed . 4. Building Permit Secured 5. Materials on Site 6. Site Preparation Completed 7. Construction 25% Complete 8. Construction 50% Complete 9. Construction 75% Complete 10. Equipment Installed (If Applicable) 11. Construction 100% Complete 12. License Obtained from DHR Office of Regulatory 90 June 2007 Services 13. New Institutional Health Service Offered 120 July 2007 14. Final Progress Report Submitted 150 August 2007 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 24 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? 0 YES [2J NO If YES ~ Complete the following table. r:F NOTE: If your components or phases exceed the number of rows in the table, attach an additional 8-}1 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 ~ Continue to the next question. COMPONENTIPHASED COMPLETION FORECAST Component, Department, or Phase Days Required to Proposed Completion Complete Date , , r:F NOTE: If litigation regarding this application, and approval thereof, occurs, the completion forecast will be adjusted at the time of the final resolution to ref/ect the actual effective date, if the final resolution is in favor of the application. Stale of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 25 32. Please provide the information in the chart below if your project involves any construction or remodeling. E7 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 renovation costs for the project. The letter must include the total square footage, the total 1. Architect cost of construction, the cost per square foot for construction, and the cost per Certification. square foot for renovations. 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. (IF" NOTE: These plans should be provided on paper no larger than 8 Y>- in by II-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 Form CON 100 Revised September 2006 Section 3 Page 26 Rule 111-2-2-.09(1)(9): 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. Intrepid plans to accept all patients in need including the financially or medically indigent, Medicaid, Peach Care, and Medicare patients. Policies and procedures relating to patient access can be found in Appendix J. o 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, Peach Care 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. Home health agencies do not have medical staff privileges. o Attach the requested policies and directives as APPENDIX J. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 27 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. Policies relating to patient payment responsibilities are contained in the Appendix. 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. As a for profit corporation, Intrepid will not receive any funds from county, city, philanthropic agencies or any other source. 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. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 28 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 Peach Care 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. As documented in the service-specific CON rules attached to this document, Intrepid plans to provides services' to Medicare, Medicaid, Peach Care, and indigent/charity patients. All patients referred to Intrepid will be served regardless of payor class or ability to pay. The pro formas contained in this application were in part based on the reported payor mix of home health agencies serving SSDR 8 residents. Itemized deductions from revenue can be found in the pro formas contained in this application (additional detail provided beyond the minimum required information). o 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? DYES ~ NO If YES ~ 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 ~ Continue to the next question. Previous Indigent/Charity Care Commitments Project Date of Percent of Adjusted Facility/Service Number Approval Gross Revenue Outcome % OMet ONot Met % OMet ONot Met % OMet ONot Met % OMet ONot Met % OMet ONo! Met % OMe! ONo!Met State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 2~ 35. Is the Applicant making an indigent and charity care commitment for this project? i:8l YES D NO If YES -+ 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 -+ Continue to the next question. Is the commitment voluntary, or is it required by a specific Certificate of Need rule? D Voluntary i:8l Mandatory Is the commitment service-specific or hospital-wide? i:8l Service-Specific D 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. Intrepid is making a mandatory indigenUcharity care commitment of 3% of Adjusted Gross Revenue. The effective date is the estimated date that the new agency will become operational (Please see the "Project Completion Forecast" table). State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 30 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. cJr NOTE: If your explanation exceeds this blocked space, attach additionaIB-Y> by 11-inch pages, number the first sheet Page 31.1, the second Page 31.2 and so on. Do not aiter the main page numbers of this application. Once printed, insert your additional pages 31.1, etc. behind this Page 31. ;?! 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 reiationship 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. The proposed establishment of a new home health agency in SSDR 8 represents a logical business decision based upon the company's existing agency in SSDR 1 D. Need in the area was identified by DCH. Home health can represent a viable alternative to inpatient care. The target population is primarily the 65+ population. Referral arrangements and working relationships with other providers are being sought throughout the review process. Evidence of these relationships will be submitted through out the review process within the timeframes specified in the CON rules and regulations. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 31 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. v.:J 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. Rule 111-2-2-.09(1 )0): 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. Ie> 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. Not Applicable. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 32 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. r,~ 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. Not Applicable. 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. '0 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. If requested, Intrepid will accommodate any clinical needs of the health professional programs serving the area. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 33 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. D 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. Home health is inherently a more cost effective alternative to inpatient care that is preferred by the vast majority of patients. The existence of a high quality agency such as that proposed by Intrepid wili foster healthy competition among the existing home health agencies serving the area. Rule 111-2-2-.09(1)(0): 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. D 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. Not Applicable. Slate of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 3 Page 34 Section 4: Service-Specific Review Considerations 43. The following table documents the service-specific review considerations currently utiiized 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 0 Adult Cardiac Catheterization Services 111-2-2-.21 0 w Open Heart Surgical Services 111-2-2-.22 0 !l: < U Pediatric Cardiac Catheterization and Open Heart 111-2-2-.23 0 w Services l- =>> Perinatal Services 111-2-2-.24 0 u < Freestanding Birthing Center Services 111-2-2-.25 0 Psychiatric and Substance Abuse Inpatient 111-2-2-.26 0 Services Skilled Nursing and Intermediate Care Facility 111-2-2-.30 0 w Services !l: Personal Care Home Services 0 < 111-2-2-.31 U :;; Home Health Services 111-2-2-.32 ~ N !l: W Continuing Care Retirement Communities 111-2-2-.33 0 I- , C) 0 z Traumatic Brain Injury Services 111-2-2-.34 e .J Comprehensive Inpatient Physical Rehabiiitation 111-2-2-.35 0 Services !l: Ambulatory Surgical Services 111-2-2-.40 0 w 0 :r Positron Emission Tomography Services 111-2-2-.41 l- e Radiation Therapy Services 111-2-2-.42 0 CONTINUED ON NEXT PAGE State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 4 Page 35 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.qeorqia.qov. 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 36.1, 36.2, etc. and insert them once printed behind this Page 36. If more than one set of service-specific considerations is applicable to your project include them behind this Page starting at Page 36.1 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) 0 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 Form CON 100 Revised September 2006 Section 4 Page 36 CERTIFICATE OF NEED 111-2-2 RULES OF DEPARTMENT OF COMMUNITY HEALTH 111-2 HEALTH PLANNING 111-2-2 Certificate of Need 111-2-2-.32 Specific Review Considerations for Home Health Services. (1) Applicability. A Certificate of Need for a home health agency will be required prior to the establishment of a new home health agency or the expansion of the geographic service area of an existing home health agency unless such expansion is a result of a non-reviewable acquisition of another existing home health agency. (2) Definitions. (a) "Home health agency" means a public agency or private organization, or a subdivision of such an agency or organization, which is primarily engaged in providing to individuals who are under a written plan of care ota physician, on a visiting basis in the place of residence used as such individual's home, part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse, and one or more of the following services: physical therapy, occupational therapy, speech therapy, medical-social services under the direction of a physician, or part-time or intermittent services of a home health aide. (b) "Horizon year" means the last year of the three-year projection period for need determinations for a new or expanded home health agency. (c) "Geographic service area" means a grouping of specific counties within a planning area for which the home health agency is authorized to provide services to individuals residing in the specific counties pursuant to an existing or future certificate of need. For purposes of establishing a service area for a new home health agency, the geographic service area shall consist of any individual county or combination of contiguous counties which have an unmet need as determined through the numerical need formula or the exception. For purposes of an expansion of an existing agency, the geographic service area shall consist of an individual county or any combination of counties which have an unmet need and which are within any planning area in which the home health agency already provides service; however, in no case may an existing home health agency apply to provide services outside the health planning areas in which its current geographic service area is located. (d) "Nursing care" means such services provided by or under the supervision of a licensed registered professional nurse in accordance with a written plan of medical care by a physician. Such services shall be provided in accordance with the scope of nursing practice laws and associated Rules. (e) "Official state component plan" means the document related to home health services developed by the Department established by the Health Strategies Council and adopted by the Board of Community Health. 36. CERTIFICATE OF NEED 111-2-2 (f) "Planning area" for all home agencies means the geographic regions in Georgia defined in the State Health Plan or Component Plan. (3) Standards. (a) The need for a new or expanded home health agency shall be determined through application of a numerical need method and an assessment of the projected number of patients to be served by existing agencies. 1. The numerical need for a new or expanded home health agency in any planning area in the horizon year shall be based on the estimated number of annual home health patients within each health planning area as determined by a population-based formula which is a sum of the following for each county within the health planning area: (i) a ratio of 4 patients per 1,000 projected horizon year Resident popufuUonage17andyounge~ (ii) a ratio of 5 patients per 1,000 projected horizon year Resident population age 18 through 64; (Iii) a ratio of 45 patients per 1,000 projected horizon year Resident population age 65 through 79; and (iv) a ratio of 185 patients per 1,000 projected horizon year Resident population age 80 and older. 2. The net numerical unmet need for home health services shall be determined by subtracting the projected number of paUents for the current calendar year from the projected need for services as calculated in (3)(a)(1). The projected number of patients for the current calendar year is determined by multiplying the number of patients having received services in each county, as reported in the most recent survey year, by the county population change factor. The county population change factor is the percent change in total population between the most recent survey year and the current calendar year. (b) 1. The Division shall accept applications for review as enumerated below: (i) If the net numerical unmet need in a given planning area is 250 patients or more, the Division shall authorize the submission of applications for an expanded home health agency; or (ii) If the net numerical unmet need in a given planning area is 500 patients or more, the Division shall authorize the submission of applications for a new home health agency as well as an expanded home health agency. 2. An applicant must propose to provide service only within a county or group of counties, each of which reflects a numerical unmet need, and contained within the given planning area for which the Division has authorized the submission of applications. 36. 2 CERTIFICATE OF NEED 111-2-2 RESPONSE: The omcial results of the above-referenced need methodology (for SSDR 8) as published in the Batching Review Notification for Home Health Services (September 24,2006) is as follows (for the counties proposed to be served by the applicant): COUNTY UNMET NEED Cbattahoocbee (94) Clay (58) Harris (204) Macon (58) Marion (33) Quitman (21) Randolph (27) Schley (35) Stewart (12) Sumter (75) Talbot (39) Taylor (46) TOTAL (702) 3. The Department shall only approve applications in which the applicant has applied to serve all of the unmet numerical need in anyone county in which need is projected. The need within counties shall not be divided or shared between any two or more applicants. RESPONSE: Intrepid plans to meet 100% of the need in each of the counties listed. The division or sharing of the need within a given county is not contemplated (c) The Division may authorize an exception to 111-2-2-.32(3)(a) if: 1. the applicant for a new or expanded home health agency can show that there is limited access in the proposed geographic service area for special groups such as, but not limited to, medically fragile children, newborns and their mothers, and HIV/AIDS patients. For purposes of this exception, an applicant shall be required to document, using population, service, special needs and/or disease incidence rates, a projected need for services in the planning area of at least 200 patients within a defined geographic service area. A successful applicant applying under this section will be restricted to serving the special group or groups identified in the application within the county or counties stipulated in the application; or 36. 3 CERTIFICATE OF NEED 111-2-2 2. a particular county is served by no more than two (2) home health agencies and either of the following conditions exists: (1) less than one percent of the county's population has received home health services, or (2) one of the two home health agencies has demonstrated a failure to adequately serve Medicaid patients as evidenced by a level of service to such individuals that is less than the statewide average within each of the past two years as reported on the Annual Home Health Services survey. For purposes of this exception, an applicant must already be approved to provide service in a contiguous county or be approved to provide service in a county that is no further than 15 miles from the county authorized through the exception. In all other aspects of the application process, the applicant shall be required to comply with provisions applicable to expanded home health agencies. For purposes of this exception, "served by" shall mean the agency(ies) are licensed to serve the county by the Office of Regulatory Services of the Department of Human Resources. RESPONSE: Not applicable to this project. (d) An applicant for a new or expanded home health agency shall provide a community linkage plan which demonstrates factors such as, but not limited to, referral arrangements with appropriate services of the healthcare system and working agreements with other related community services assuring continuity of care focusing on coordinated, integrated systems which promote continuity rather than acute, episodic care. Working agreements with other related community services may include the ability to' streamline referrals to other appropriate services and to participate in the development of cross-continuum care plans with other providers. RESPONSE: Communi(v Linkaf.:e Plan In order to develop community linkages, Intrepid plans to hire community linkage personnel. For example, Intrepid plans to place Home Care Coordinators on-site at area hospitals to assist hospital staff in the coordination of patient care. Another position, Clinical Nurse Liaisons will serve as liaisons with the community. A third level of community linkage personnel, Account Managers, will function as marketing representatives that will establish relationships with physicians, nursing homes, rehabilitation centers, personal care homes, and other potential referral sources. STEPS TO ACCOMPLISH: (I ). Identity appropriate community linkage contacts in the proposed service area, e. g., key physicians, hospitals, .nursing homes, assisted living facilities, patient advocacy groups. (2). Use Agency community linkage personnel to work with area providers to develop community linkages. (3). Annually re-evaluate the program and modity as necessary. To pinpoint potential hospital linkages, the following information shows the inpatient destinations tor SSDR 8 residents. Intrepid plans to establish referral arrangements with these hospitals and other hospitals serving the service area residents. 36. 4 CERTIFICATE OF NEED 111-2-2 General Hospital Inpatient Cases, SSDR 8 Counties 55 Hospital dr County Area Servedl General Hospital Total MS% Pat04 Pat04 TOTALS 13.869 100.0 8 Sumter Sumter Regional Hospital 3,911 28.2 10 Dougherty Phoebe Putney Memorial Hosp 1,593 11.5 8 Muscogee Medical Center Columbus 1,248 9.0 8 Muscogee SI Francis Hospital 1,039 7.5 8 Macon Flint River Community Hosp 1,167 8.4 8 Muscogee Doctors Hospital Columbus 641 4.6 8 Stewart Stewart Webster Hospital 444 3.2 6 Bibb Medical Center Central Ga 654 4.7 8 Randolph Southwest Georgia Reg Me 262 1.9 4 Upson Upson Regional Medical Center 337 2.4 4 Troup West Georgia Medical Center 231 1.7 8 Muscogee Hughston Sports Med Hasp 378 2.7 10 Dougherty Palmyra Medical Centers 202 1.5 6 Houston Houston Medical Center 279 2.0 3 DeKalb Emory University Hospital 209 1.5 6 Houston Perry Hospital 128 0.9 6 Bibb Coliseum Medical Centers 142 1.0 6 Peach Peach Regional Med Ctr 73 0.5 4 Meriwether Georgia Baptist Meriwether 134 1.0 3 DeKalb Childrens Healthcare Atl Egles 75 0.5 7 Richmond Medical College of Ga Hosp 52 0.4 8 Crisp Crisp Regional Hospital 59 0.4 6 Bibb Middle Ga Hasp (mrgMCCG) 0 0.0 6 Bibb Macon Northside Hospital 45 0.3 10 Early Early Memorial Hospital 28 0.2 3 Fulton Crawford Long Hospital 34 0.2 3 Fulton Piedmont Hospital 27 0.2 2 Towns Chatuge Regional Hospital 149 1.1 3 Fulton St Josephs Hosp Atlanta 18 0.1 3 Fulton Childrens Healthcare Atl SRite 21 0.2 10 Calhoun Calhoun Memorial Hospital 12 0.1 3 Fulton Atlanta Medical Center 16 0.1 7 Richmond Doctors Hospital Augusta 29 0.2 3 Fulton Northside Hospital 13 0.1 3 DeKalb OeKalb Medical Center 8 0.1 3 Clayton Southern Regional Med etr 16 0.1 6 Pulaski Taylor Regional Hospital 13 0.1 3 Fulton Grady Memorial Hospital 20 0.1 SOURCE: OS DHP AHQ, Inpatient cases (DisJAdms), 09115/06 NOTE: Documentation of Community Linkages is contained in Appendix N. (e) An applicant for a new or expanded home health agency shall provide a written statement of its intent to comply with all appropriate licensure requirements and operational procedures required by the Office of Regulatory Services of the Georgia Department of Human Resources. 36. 5 CERTIFICATE OF NEED 111-2-2 RESPONSE: Intrepid formally commits to comply with all appropriate licensure requirements and operational procedures required by the Office of Regulatory Services of the Georgia Department of Human Resources. (f) An applicant for a new or expanded home health agency or agency(ies) owned and/or operated by the applicant or its parent organization shall have no history of uncorrected or repeated conditional level violations or uncorrected standard deficiencies as identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. RESPONSE: Neither Intrepid nor any affiliated company has a history of uncorrected or repeated couditionallevei violations or uncorrected standard deficiencies as identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. (g) An applicant for a new or expanded home health agency or agency(ies) owned and/or operated by the applicant or its parent organization shall have no previous conviction of Medicaid or Medicare fraud. RESPONSE: Neither Intrepid nor any of the companies associated with Intrepid have ever been convicted of Medicaid or Medicare fraud. (h) An applicant for a new or expanded home health agency shall provide a written plan which demonstrates the intent and ability to recruit, hire and retain the appropriate numbers of qualified personnel to meet the requirements of the services proposed to be provided and that such personnel are available in the proposed geographic service area. RESPONSE: [Also, please see Policy # 3.013 "Recruitment, Interviewing, Hiring and Retention" contained in the Appendix] The company will use several means to recruit employees. All recruitmeut efforts are aimed toward recruiting a diverse, competent and skilled workforce. The following recruitment options include but are not limited to: I. Posting on the Company's Website and other website postings 2. Print advertising to local publications and newspapers 3. Job fairs 4. Open houses in Agency 5. School recruiting 6. Recruiting to diverse groups in accordance with our Affirmative Action plan 7. Employee referral 8. Sign-on bonuses On-going education is accomplished through a variety of means including "Intrepid University", an on-line continuing education program (additional detail can be found in the Appendix). (i) An applicant for a new home health agency shall provide evidence of the intent to meet the appropriate accreditation requirements of the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc. (CHAP), and/or other appropriate accrediting agencies. 36. 6 CERTIFICATE OF NEED 111-2-2 RESPONSE: Intrepid plans to seek CHAP accreditation if approved for the new agency. Intrepid has contacted CHAP and informed the organization of the company's plan to seek accreditation if the application is approved. (j) An applicant for an expanded home health agency shall provide documentation that they are fully accredited by the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc. (CHAP), and/or other appropriate accrediting agency. RESPONSE: Not applicable to this project. (k) An applicant for a new or expanded home health agency shall provide its existing or proposed plan for a comprehensive quality improvement program. RESPONSE: Intrepid has a comprehensive Quality Improvement Program (documentation is contained in Appendix N). (I) An applicant for a new or expanded home health agency shall assure access to services to individuals unable to pay and to all individuals regardless of payment source or circumstances by: 1. providing evidence of written administrative policies that prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or ability to pay; RESPONSE: Please refer to Appendix N. 2. providing a written commitment that services for indigent and charity patients will be offered at a standard which meets or exceeds three percent of annual, adjusted gross revenues for the home health agency or, in the case of an applicant providing other health services, the applicant may request that the Division allow the commitment for services to indigent and charity patients to be applied to the entire facility;, RESPONSE: Intrepid formally commits to provide indigent/charity care at a level of 3% of AGR. 3. providing documentation of the demonstrated performance of the applicant, and any facility in Georgia owned or operated by the applicant's parent organization, of providing services to Medicare, Medicaid, and indigent and charity patients; RESPONSE: The existing, operational agencies provide services to Medicare, Medicaid and indigent/charity populations. For example, during 2005, Intrepid's three agencies served 283 Medicaid patients, 1,019 Medicare patients, and provided service to Indigent/Charity patients (discussed above). Additional detail can be found in the Appendix. 36. 7 CERTIFICATE OF NEED 111-2-2 Intrepid USA Healthcare Services Georgia Payor Mix, 2005 Medicare 65.2% Self Pay 0.3% SOURCE' Home Health Su"'ey. 2005. DCH Figure 1 Durin!? 2()()5, Intrepid provided services to Medicaid, Medicare and other payor classes. 4. providing a written commitment to participate in the Medicare. Medicaid and Peach Care programs; and RESPONSE: Intrepid plans to participate in Medicare, Medicaid, and Peacheare at the new agency and formally commits to participate in these programs if the application is approved. 5. providing a written commitment to participate in any other state health benefits insurance programs for which the home health service is eligible. RESPONSE: Intrepid timnally commits to participate in any other state health benefits insurance programs for the home health service is eligible. (m) An applicant for a new or expanded home health agency shall demonstrate that their proposed charges compare favorably with the charges of existing home health agencies in the same geographic service area. RESPONSE: The Annual Home Health Survey instrument does not collect charges by discipline; therefore, comparable charge data is not available. An average gross charge is a meaningless statistic since the average is driven by the discipline mix. For example, a home health provider with a high percentage of home health aide visits will have a lower average charge than a provider with a high number of skilled nursing visits. Furthermore, home health agencies are under a prospective payment system which pays providers a uniform rate regardless of cost or charges which makes charges meaningless. (n) An applicant for a new or expanded home health agency shall document an agreement to provide Division requested information and statistical data related to the operation and provision of home health services and to report that data to the Division in the time frame and format requested by the Division. 36_ 8 CERTIFICATE OF NEED 111-2-2 RESPONSE: Intrepid formally agrees to provide the Division any and all requested information and statistical data related to the operation and provision of home health services and to report that data to the Division in the time frame and fannat requested by the Division. (0) The department may authorize an existing home health agency to transfer one county or several counties to another existing home health agency without either agency being required to apply for a new or expanded certificate of need, provided the following conditions are met: 1. the two agencies agree to the transfer and submit such agreement and a joint request to transfer in writing to the department at least thirty (30) days prior to the proposed effective date of the transfer; 2. the two agencies document within the written request that the transfer would result in increased and improved services for the residents of the county or counties including Medicare and Medicaid patients; 3. the agency to which the county or counties are being transferred currently offers services in at least one contiguous county or within the health planning area(s) in which county or counties are located; and 4. the two agencies are in compliance with all other requirements of these Rules; such compliance to be evaluated with the written transfer request. No such transfer shall become effective without written approval from the department. RESPONSE: Not applicable to this application. 36. 9 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 ture of Authorized Signatory (BLUE INK ONLY): ew\J.-l\, . Newell D. Yarbo 0 gh. Jr Title: Consultant Date: 11/8/06 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Applicant Certification Page 37 INTREPID SSDR 8 CON ADDITIONAL APPENDIX ITEMS' APPENDIX G Detailcd Pro Formas & Assumotions Geor"ia HHA Pavor Data APPENDIX N MDC & Product Line Reoorts Other Policies & Procedures (Scope of Scrvices, Clinical Specialty Programs, Affirmative Action, HIPPS Privacy, Comoliancc Trainin. & Education, In-Service Program, Corporate Comnliance ProQram) Admissions Policv Recruitment ProQram (and infonnation on Intreoid University) * Represents additional items beyond the requirements for completeness. AP):'ENDIX A ( County Commission Transmittal Cover Letter ,.. ~,,- , ,. I' 1 i I, I; I' I: I I " 1 I' I: Ii , I, I 1 , ., I. I' II YARBOROUGH Consulting, Inc. UU H\RSH EIXJE L\I\:F. S_-\\~-\NN'\Il. r.EOltGIA JH1':t 911'l2Vill% (f)'l12-'IlS-Ol07 e-mail: l"D\"@AOI..(:O/l,J November 2, 2006 Via FedEx Ground Christopher Ryan, Clerk SUMTER COUNTY BOARD OF COMMISSIONERS 605 Spring Street Americns, Georgia 31709 RE: Certificate of Need Application; Intrepid USA Healthcare; Establish a New, Medicare Home Health Agency; SSDR 8 Dear Mr. Ryan: Enclosed please find your copy of the above-referenced application. No response or action is required on your part. The Georgia Certificate of Need rules require that you be provided with a copy of the application. ;r:VtD~ Newell D. Yarborough, Jr. President attachment APPENDIX A Survey Statu,lIndigent Care GEORGIA DEPARTMENT OP COMMUNITI HEALTH Rlwnda M. Mcdow,l", MD. Commissioner Sonn:\! Perdue. Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Division of Health Planning Suite 5-200 Main: (404) 656.0655 Fax: (404) 656-0654 To: Clyde L. Reese, III Reese & Hopkins, LLC (on behalf of Intrepid USA Home Health Services) 84 Peachtree St., NW Suite 600/Flatiron Bldg. Atlanta, GA 30303 NOTICE OF COMPLIANCE FOR SURVEY AND INDIGENT AND CHARITY CARE COMMITMENT REQUIREMENTS As of the date below, the following proposed applicant or organization HAS MET the requirements for submission and completeness of all surveys and has fulfilled active indigent and charity care commitments or other required data appropriate to the filing of the Certificate of Need Project described below and pursuant to DCH Rules 111-2-2- .06(4)(b)5 and 111-2-2-.06(4)(b)11: Applicant or Organization: Intrepid USA Home Health Services (DHP Reference #: 8-N-2) Project Description: To establish a new home health agency to serve Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, and Taylor Counties in SSDR 8. Note: A separate CON application must be submitted for new or expanded home health agency services for each planning area (SSDR) proposed. A certificate of survey and commitment compliance must be included in each application. Applications must be filed by November 13,2006, at 12:00 pm. ~~ Certified By: Matthew Jarrard, Statistical Unit Chief Division of Health Planning Date Certified: October 17, 2006 Equal Opportunity Employer . APPENDIX B Licenses/Permits DEPARTMENT OF HUMAN RESOURCES STATE OF GEORGIA LICENSE This is to certify that a license is hereby granted to F.C. OF GEORGIA, INC. (Name of GoVerning Body) to maintain and operate a Home Health Agency with 5 (No.) INTREPID USA HEAL THCARE SERVICES branch office(s) named as (Name. of Agency) located at 101 F NORTHSIDE DRIVE. SUITE 1 (Street) in VALDOSTA (City or Town) , County of LOWNDES , Georgia Approval is granted to provide the following services: HOME HEALTH AIDE, MEDICAL SOCIAL WORKER, NURSING SERVICE, OCCUPATIONAL THERAPY, PHYSICAL THERAPY AND SPEECH THERAPY. Service Area approved for this agenc BERRIEN, BROOKS, CLINCH, COOK, ECHOLS, LANIER AND LOWNDES COUNTIES. This license is effective during the period: October 01, 2006 thru September 30, 2007 unless revoked or suspended. "This permit is granted pursuant to the authority vested in the Department of Human Resources, by the Official Code of Georgia Annotated Title 31, Chapter 7 and signifies that its facilities and operations comply with the Rules and Regulations of the Department .of Human Resources on the date this permit was issued," THIS LICENSE. IS NOT TRANSFERABLE license No: 092-275-H OFFICE OF REGULATORY SERVICES GEORGIA DEPARTMENT OF HUMAN RESOURCES ~~~ ~~ ~c.0, Interim Director, Office of Regulatory Services DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES I A I EMENT OF DEFICIENCIES /"- ---IAN OF CORRECTION (X1) PROVIDERISUPPLlER/ClIA IDENTIFICATION NUMBER: 117073 '-JAME OF PROVIDER OR SUPPLIER INTREPID USA HEALTHCARE SERVICES I I G 000 ! INITIAL COMMENTS (X4) ID PREF!X TAG SUMfAARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Intrepid USA Healthcare Services is in substantial cDmpliance with 42 Part 484 requirements for I Home Health Agencies as a result Df a recertification survey conducted 01/21/05. The following standard level deiiciencies were cited: G 158 484.18 ACCEPTANCE OF PATIENTS, POC, MED SUPER I Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine. This STANDARD is not met as evidenced by: Based on record reviews and staff interviews, it was determined the agency failed to iollow the plan of care for assessments, medication administration, and visit frequencies ior 6 oi 15 I patients (#1, 3,11,12,13,14) sampled. Findings I were: I . 1. The plan of care ior patient #14 ior certification period 11/22/04 to 01/20/05 required the skilled nurse to administer Zoladex (medication ior i prostate cancer) subcutaneously in the right I upper quadrant of the abdomen. Documentation Ion 11/23/04 revealed the the skilled nurse administered Zoladex in the right lower quadrant oi the abdomen instead oi the upper abdomen. 2. The plan of care for patient # 1 ior certification I period 11/09/04 to 01/07/05 required the skilled I nurse to assess the gastrostomy tube (G tube) site. The skilled nurse iailed to assess the G tube site on 11/12/04, 11/19/04, 12/2/04 and 12/27/04, PRINTED: 01/25/2005 FORM APPROVED OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. n!!II.f)ING (X3) DATE. SURVEY COMPLETED 8, WING . 01/21/2005 STR::ET ADDRESS, CITY, STATE, ZIP CODE 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CP,QSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (XS) COMPLETION I DATE. G 000 G 1581 Alimin~sfrator/DOPS will provide education to all staff on the. 102/20/05 following: 1. lnservice will be held with all staff on providing care accordingto MD orders. 2. Inservice will be held to emphasize accurate documentation of medication orders and j administration of medications. ;~~~~e:~~~i~~C~~d:o:~~~r:~: loc'tion. Supervisor will review orders prior to release for 11D signature to ensure accuracy of orders. Administrator/DOPS will rev.iew 02/20/05 the process of scheduling visits according to MD orders per J Medicare criteria and every I 60 day episo~e' Agency will imp~ement the Mckesson sphedulef computer prop:ram which will alert age!lcy daily of visits made II outside of MD orders such as ~issed v~~its' or extra vi~it~. I I I )RATO~Y.GltRECTOR'S OR P~0-\lJDERlSUPPLl~R ~JPKESE~ATIVE'S SIGtlll,TUR,~-\ :\ _~~( --r">' r (~6) OAT<=; , -I. () I I \. I.' L. ~o{ i ".-". . ( b:j "J c.~_- ._~9.~' -L".___...../ \._"~lt( s-- ,.~L...L_vL--:.-:-.yC,<.(3'-/i t~./____ "~-.I.},' O. L,~.,den~~tatement ending wiih~ asterisk ("') denotes a deficiency which the institution may be excused from correcting providing it is d~tertnined that r safeguards provide sufficient protection to the patIents. (See instructions.) Except for nursing homes, the findings stated above are disciosable 90 days ving the daie of survey whether or no! a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosabJe 14 following the date these documents are made avaHa!:lle 10 the facility. If deficiencies are cited, an approved plan of correction is requisite to continued 8mpartici~tion. . 11 CMS-2567(02-99) Previous Versions Obsolete EvenllD: E1D611 Facility 10: GA117073 If continuation sheet Page 1 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT Of DEF1CIENCI!:S c"t-'r; PLAN OF CORRECTION (X1) PROVIOERISUPPUEPJCUA IDENTIFICATION NUMBER: 117073 NAME OF PROVIDER OR SUPPLIER INTREPID USA HEAL THCARE SERVICES (X4) 10 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FUll REGULP.TORY OR LSC IDENTIFYING INFORMATION) G 158 Continued From page 1 which was 4 of 7 skilled nurse visits. 3. A verbat order dated 12/21/04 for patient #11 required the skilled nurse to administer vitamin B-12, 2 ccs intramuscularly (1M) one time a month. Documentation by the nurse indicated administration of B-12 1cc 1M on 01/17/05, which is half the ordered dose. The nurse, therefore, failed to administer the correct dose of vitamin B-12. Interview will1 the agency administrator on 01/21/05 at approximately 10:30 a.m. confirmed that an incorrect dose of 8-12 had been administered on 01/17/05. . 4. The plan of care for patient # 12 required home health aide services three times per week. The I clinical record lacked evidence of one visit the . week of 01/03/05. The physician was not notified of the missed visit by the aide. An interview with the Administrator and the I Director of Operations on 01/20/05 at 3:15 p.m., I confirmed that the physician was not notified of the missed visit the week of 01/03/05. 5. The plan of care for patient #13 required the home health aide to visit 1 time a week for 1 week, then 3 times' a week for 8 weeks. The record lacked evidence of one visit the week of 11/29/04. Interview with the administrator on 01/20/05 at 'I approximately 12:30 p.m. confirmed a missed aide visit the week of 11/29/04 and that the ~M CMS-2567(02-99) Previous Versions Obsole!e EvenllD: E1D611 (X2) MULTIPLE CONSTRUCTION A. aWIWIW, PRINTED: 01/25/2005 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED 8. WING 01/21/200S STREET ADDRESS, CITY, STATE, ZIP CODE 106 NORTH SIDE DRIVE VALDOSTA, GA 31602 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 158 Administrator/DOPS will review the process for documenting missed visits and notifying MD of missed visits. Conti'nued' comii'.liance will be I moni~or~d by reviewing 30% of all. me.dlcal records for 3 mont.hs. Monitaring will completed by I Administrator!DOPS and Supervi~ors Five -- Seven audits will be j conducted weekly to ensure compliance" '1.S demonstrated on a timely ban is . . As compliance is shown~ monitor:ng will be decreased to standard medical review wich is 10% of active and 10% of inactive patient reGords per month. 02/20/05 . I I I I I I I I I Fadll1y ID: GA117073 If continuation sheet Page 2 of 6 . DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ANr) PU..N OF CORRECTION" (Xi) PROVIDERfSUPPLlER/CLfA IDENTIFICATION NUMBER: 117073 NAME OF PROVIDER OR SUPPLIER INTREPID USA HEAL THCARE SERVICES (X4) ID PREFIX TAG SUMMARY STATEMeNT OF DEFICJENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 158 Continued From page 2 physician was not notified of the missed visit. 6. The clinical record for patient # 3 contained documentation by the skilled nurse on 12/21/04, 12125104,01/05/05, and 01/14/05 that indicated I that the visits were missed. The record lacked evidence that the physician was notified of the missed visits. An interview with the Administrator and the I. Director of Operations on 01/21/05 at 10:10 a.m., confirmed that the documentation that indicated ! the physician was notified of the missed visits was not available. 164. 484.18(b) PERIODIC REVIEW OF PLAN OF [CARE Agency professional staff promptly alel1 the physician to any changes that suggest a need to aller the plan of care. ! This STANDARD is not met as evidenced by: I Based ori record reviews and staff interviews, it was determined that the agency failed to notify the physician of changes in patient status, failure to obtain medication, and missed visits which I suggested a need to alter the plan of care for 4 of 113 patients (#1,4,5,6) sampled. Findings were: I 11. Patient # 1 was admitted to the agency I 03/20/03 with the pertinent diagnosis of I I hypertension and diabetes. The clinical record I revealed that the patient's blood pressure was I elevated and the physician was not notified on the I following days: I I v1 CrvlS-2567(02-99) Previous Versions Obsolete Event 10: E1D611 (X2) MULTIPLE CONSTRUCTION A RIIII nlNG PRINTED: 01/25/2005 FORM APPROVED OMB NO 0938-0391 (X3) OA TE SURVEY COMPLETED 8. WING 01/21/2005 STREET ADDRESS, CITY, STATE, ZIP CODE 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EA.CH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 158/ I I G 164 Administrator/DOPS will provide I an inservic8 on the following: 1. An inservice will b9 held 02/20/05 regarding when to call MD of changes in pati~nt sta'tus and what parameters are used to i.dentify I remarkable findings. Staff will be instructed to include in I orders parameters for reportiEg B/P and BS on all patients with diagnosis of HTN and da.-~betes. 1 2. An inservice w.ill be conduct:: d wifh,:;all professional staff on when to notify MD of renarkable findings during assessments. Emphasis wJll be placed on the timeliness or notification and ac'curate documentation. 3. An inse':'vice will be held to I :~~~;~~;:~~~~~:~Dn~~~f~~~~m~~tll:!!g of fu,LSSe(. VLS_tS. Facility ID: GA117073 If continuation sheet Page 3 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES ')'~ PV\N OF ~ORRECTION (X1) PROVIDERiSUPPLJERJCLlA IPeNTlFICATION NUMBER; 117073 NAME OF PROVIDER OR SUPPLlt::R INTREPID USA HEAL THCARE SERVICES . (X4)ID PREFIX TAG SUMMARY STA TEfI..1ENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULA.TORY OR LSC IDENTIFYING INFORIv1ATION) G 1641 Continued From page 3 1 Documentation indicated that the patient's blood pressure was 198/107,168/90,180/80, 192/88, 192/92,180/100,180/96 and 184/90 on 11/11/04, 11/18104, 11/24/04, 12/27104, 01/14105, 11/10104, 11/24/04, and 12/29/04, respectively. An interview with the Administrator and the 1 Director of Operations on 01/20105 at 4:00 p.m., I confirmed that the patient's blood pressure was' elevated and the physician was not notified. ! 2. Patient # 6 was admitted to the agency for physical therapy services. The start of care assessment, completed by the physical therapist, I revealed that the patient had a burning sensation I while urinating. The physical therapist failed to , I notify the physician of the patient's burning during I urination. An interview with the Administrator and the Director of Operations on 01/20/05 at 3:00 p.m., I confirmed that the physician was not notified of the patient's burning when urinating. 13. Docurnentation by the skilled nurse dated 112/23/04 for patient #4 indicated a new skin tear I ~~ ~",~~i;h~~a~fr;:o~dul~~~e~ c:v~~~~~~~~~cms) I physician was notified of the new wound until 112/27/04. The nurse also noted the right heel I wound to have a large amount of serous, bloody , and purulent drainage with a foul odor present, and that the surrounding tissue had a greying color which was a new finding. The nurse failed to notify the physician of changes in the patient's wound status. M CMS-2567(02-99) Previous \/~rsions Obsoleie EvenllD: E1D611 PRINTED: 01/25/2005 FORM i',PPROVED OMS NO 0938-0391 (X2) MUL TJPLE CONSTRUCTION A RIIII hIW~_ (X3) DATE SURVEY (',OMP\ FTFO B. WING 01/21/2005 STREET ADDRESS, CITY, STATE, ZIP CODE 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 ID I PREFIX TAG I PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFJCIENCY) (X5) COMPLETIO~! DATE , . I Contirll12d C'.omp~Jance vrill. i.,be /2/2.0/('5 ffionitored by reviewing 30% of all medi~a~ recrrds for 3 months. HOil ~toTing will camp let'?': by ! AdmLu~str~tor!DOPS and ~liPerViOSl~rs. :' ivr~ -seveT aLld lr:s \vill t'e ~orducred weekly to ensu]-e _ c-Dmpliance is oemonstrate.d in a a timely faE,hion. 1 As compli_ance iE; 'ShUllt.1Hj monitor:img >:-::L11 b~ (iecT.'~ased to standard 1 medical review which lS 10% of G 164 a.ctive 2-.nJ 10'% ~)f ina.ctive pat:ieT!.1 l'J.::corts peT montk'~',,- FaCility ID: GA11"1073 If continuation sheet Page 4 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES 'l,f'Ir. PLAN OF CORRECTION (Xl) PROVIDERISUPPUER/CUA IDENTIFICATION NUMBER: 117073 NAME OF PROVIDER OR SUPPLIER INTREPID USA HEALTHCARE SERVICES (X4) ID PREFIX TAG SUMMARY S I ATEMENT OF Dt:.FIC1ENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR lSC IDENTIFYING INFORMATION) G 164 Continued From page 4 I 4. The plan of care for patient #5 for certification period 12/11104 to 02/08/05 required wound care to include packing with ChlorapaCtin when available. The record lacked evidence the physician was notified that the chlorapactin was unavailable during the time period 12/11/04 to 01/04/05. Interview with the administrator 01/21/05 at approximately10:30 a.m. failed to provide evidence the physician was notified that the Chlorapactin was unavailable, which may have suggested a need to aiter the plan of care. ~ ?141484,36(b)(2)(ii) COMPETENCY EVALUATION & IN-SERVICE TRAI The I-IHA must complete a performance review of each home health aide no less frequently than I every 12 months. This STANDARD is not met es evidenced by: Based on review of home health aide personnel records and steff interview, it was determined that I the agency failed to complete a performance ! review within 12 months for 2 of 4 (#2 and 4) I home health aides samoled. Findinos were: 11,The last performance review far a:e #2 was I completed on 08/13/04. The previous performance review was conducted 07/09/03 resulting in the performance review being 35 days late. 2. The last performance review for aide #4 was completed on 08/13/04. The previous performance review was conducted 0/16/03 1 CMS-2567(02-99) Pre\lious Versions Obsolete EvenllD: E1 D611 (X2) "UL TIPLE CONSTRUCTION PRINTED: 01/25/2005 FORM APPROVED OMS NO 0938-0391 . (X3) DATE SURVEY COM PI FTFn A Hlllllllhl/'; B, WING 01/21/2005 STREET ADDRESS, CITY, STATE, ZIP CODE 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 164 . . G214 AdministratorjDOPS will review the human resource tracking log weekly for expiring evaluations. Performance evaluations will be conducted up to 2 weeks prior to last evaluation. Continued compliance will be monitored by reviewing 50% (11 charts) monthly or all empl yee charts ror 3 months. Two~three audits will be performed weekly t.o ensure ongoing compliance. Monitoring will be ~ompleted by Administrator and DOPS. As continued compliance is ShOWi monitoring will be decreased- to standard employee review which is I four employee charts a month. I Facility 10: GA117073 If continuation sheet Page 5 of 6 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES ;T A TEMENT OF DEFICIENCIES \~'- DU\N OF CORRECTION (X1) PROVIDERISUPPLlER/ClIA IDENTIFICATION NUMBER: 117073 \lAME OF PROVIDER OR SUPPLIER INTREPID USA HEAL THCARE SERVICES (X4) 10 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR lSC IDENTIFYING INFORMATION) G 214 Continued From page 5 resulting in the performance review begin 58 days late. Interview with the administrator on 01/19/05 at approximately 4:15 p.m. confirmed that the performance reviews were not completed within a 12 month period. I I \11 CMS-2567(02-99) Previous Versions Obsolete EvenllO: E1D611 (X2) MUL TI?LE CONSTRUCTION A RIIII nll\\(; B. WING STREET ADDRESS, CITY, STATE, ZIP C9DE 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 I I 10 PREFIX TAG G 2141 PRINTED: 01/25/2005 FORM APPROVED OMS NO 0938-0391 (X3) DATE SURVEY COMPLETED 01/21/2005 PROVJDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (X5) I COMPLETJON DATE I Facility ID: GA 117073 If continuation sheet Page 6 of 6 . State of Georqia, Office of Reculatory Services -::Man OF OEFIClaJC)CD LAIJ Uf CUHHoC IIUN 1'1';'11 F'ROYjIJEHi,SUh~LI!::.19U,IA IDEN-m.ICA liON NUMBER' , ,-,,~ AME of PROVIDER OR SUPPLIER 092.275.H S I REE I ADDRESS, CITY. STATE, ZIP CODE 01/21/2005 NTREPID USA HEAL THCARE SERVICES I I I I X 0001 INITIAL COMMENTS' I I I At the time of the survey, Intrepid USA I Healthcare Services was in substantial I compliance with the Rules and Regulations for I Home Health Agencies, Chapter 290-5-38, as a I result of a state licensure survey, The following deficiencies were cited. X 0711290.5.38-.09 STANDARDS FOR PATIENT i C,n,RE II Patients shall be accepted for treatment on the basis of a reasonable expectation that the . I patient's medical, nursing, and social needs can , 1....- ........,..,~ ,.., _l,..,~, ,,..,';'_Iy 1.-." ~l~ _ ~~,..,~_" '," 'h- v-.,..,,l.;__Lts I I ~~~:~~~t~~~~:~~~. p~t:j~~l~:;~;~U ~~~ibe~d~~~~- ) services because or their age, sex] race, religion, I or national origin, Care shall follow a written plan I of treatment established and periodically I i reviewed bya phYSICian, and shall continue under i I me superVIsion OT 3 pnYSIClan.' ! I ' i I I This Rule is not met as eVidenced by: ! Based on record reviews and staff interviews, it [I was determined the agency failed to follow the I plan of care for assessments, medication ) : administration, and visit frequency for 6 of i5 I I patients (#1,3, i 1,12, 13, 14) sampled. Findings I Iw~~ I 11, The plan of care for patient #14 for I I' certification period 11/22104 to 01/20/05 required I the skilled nurse to administer Zoladex ' I (medication for prostate cancer) subcutaneously I I in the right upper quadrant of the abdomen, I I Documentation on 11/23/04 revealed the the I I skilled nurse administered Zoladex in the right I lower quadrant of the abdomen instead of the I I - __.. -'. I :.iion Report,' \ \r: "J ~'_~}__J/) ". ~.___~A)-.,~ (>.._/{~~>\-S-::?::", '\ /!:::~~J Al0,:::;:Y DIRECTOR'S OR PROVID=.~/SUPPLlER REPRESENTATIVE'S SIGNATURE (X4) ID PREfIX TAG SUMMARY STATErv'lENi OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORhA PRINTED: 01/25/2005 FORM APPROVED (t7) 11ill II TIPI F r,nt1l.STRlllrlnhl A. BUILDING 8. WING (:,':3) Df,TE SURVEY COMPLETED X 071 8~.9 , PROVIDER'S PUN OF CORRECTION (EACH COHRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X:5) COMPLETE: DATE 106 NORTHSIDE DRIVE V ALDOST A, GA 31602 I 10 I I PREFIX I I TAG I I X 000 I ! Adminstrator/DOPS will provide 02/20/05 education to all staff on the following: 1. Inservice will beheld with all staff on providing care according to MD. orders. I 2. Inservice will be held to elllphasize accurate doc~mentati?n . of medication orde'rs ana administratioL of medication, which will include accurate. documentat.ion of dosa~e. and. location. Su~ervisor ~ill I reVlew orders prlor to release, for MD signature to ensure I accuracy of orders. Administrator/DOPS will revie~b2/20/05 the process of schedullng Vl8]-:~8 according to MD orders per ) Medicare criteria and every 601 day episode. Agency will implement the Mckesson scheduler computek program ~hich will alert the I agency daily of visits made I outside of MD orders suc~ ~s I missed visits or:'extra V1SltS.! i ! I I ! i , , TITLE (X6) DA~E (\, _.~,- f) ..:....-___{L. <.-,j ~ i _.~_ \ :I~ r~ --v\/__L-., ,-j.\-"Lt c?j"-C'~' -:Sf 3/ b s: E 1 D611 If conlinuiltick1 shddi 1 of 5 ~ State of GeorQia Office of R~oulatorv Ser\'ic~s PRINTED: 01/25/2005 FORM APPROVED - . - ['.7 --:MENT OF DEFICIENCIES ,X I'i PROVlfIfRI,lIIPPIIFRII',IIi\ ('1-1) I,n! (I 'rIp! F r:(I~!'rrp.Utll('r'.1 IX"I PATF ,11IRVf'r' ft.1 ,.Jill 01. CU!~j\L:C IIUN IDENTIFICATiON NUMBER: COMPLETED ,0... BUILDING B. WING 092-275-H 01/21/2005 NAME OF PROVIDER OR SU??L1=.R STREET P'oDRESS. CITY, STATE, ZIP CODE INTREPID USA HEAL THCARE SERVICES 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 (X4) 10 , SUMh'lARY STATEMENT OF DEt-ICIENCJES I ID i PROVIDER'S PLAN OF CORRECTION i , , (X5) PR::::F1X , (EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE i COMPLETE , PREFIX I , TAG I REGULP.TORY OR LS~ IDENTIFYING INFORMATION) I TAG I CROSS-REFEREtKED TO THE APPROPRIATE DATE I DEFICIENCY) I , I ,. I , I X 0711 Continued From page 1 X 071 I I I upper abdomen. Administrator/DOPS will reviewI02/20/0S I the process for do-cumenting I I 2. The plan of care for patient # 1 for certification I I period 11/09/04 to 01/07/05 required the skilled I missed visits and notifying I I nurse to assess the gastrostomy tube (Gtube) I,m of missed visits. , I site. The skilled nurse failed to assess the G Continued compliance will be I I tube site on 11/12/04, 11/19/04, 12/2/04 and 12/27/04, which was 4 of 7 skilled nurse visits. monitored by reviewing 30% of I 13 "voeb~1 oe~~r ~a+ed 1~'21 '0' 'oe Mt'e~t "1' all medical records for 3 montns. I Monitoring will be completed I I ., v,.... '\.tv '-', '''-' J.... I '1-'0 I II r.- I by Admininstrator/DOPS and I ' required the skilled nurse to administer vitamin i B-12, 2 ce's intramuscularly (1M) one time a Supervisors. Five-seven audits I i month. Documentation by the nurse indicated I will be conducted weekly to administration of B-12 1cc 1M on 01/17/05, which ensure compli.ance is demonstraFed - " " I ",I~~ h-lf ~hc> r!....,s~ ,h~ 0;"'--8 ~,.,d",,-. ,F'. .....,..,'""",....,,,l"'r I " .,c;::; "C" ",..... '""v...... "'..... "UI~ 'OI/e,J IV <;:'UIII"I';:::"C I i the correct dose aT 8-'12 ordered. i [Interview with the agency administrator on i i 01/21/05 at'approximately 10:30 a.m. confirmed II I that an incorrect dose of B-12 had been administered on 01/17/05. I I ~. The plan of care for patient # 12 required home I ,ealth aide services three times per week. The I iinical record lacked evidence of one visit the I eek of 01/03/05. The physician was not notified the missed visit by the aide. I I I I I I I , I , I on a timely basis. I As complianc-e is shown, monitoring . I will be- decreased to standard 1 medical re';'iew which is 10% ofl active and 10% of inactive i , patient records per month. I I , I I I , I interview with the Administrator and the ctor of Operations on 01/20/05 at 3:15 p.m., irmed that the physician was not notified or 1issed visit the week of 01/03/05. , plan of care for patient #13 required the '1ealth aide to visit 1 time a week for 1 hen 3 times a week for 8 weeks. The acked evidence of one visit the week or 1. with the administrator on 01/20/05 at S5~~ E1D611 If continlJaiion sheet 2 of 5 State of Georaia, Office of Requlatory Services $" TEI'..1ENT OF DEfiCIENCIES r L,l}~ Of C":'R.R.EGTJON (:<1) PROV/DERISUPPLIER/CLlA IDENTIFlCA 1I01~ I,IUMBER, 092-275-H NAME Of PROVIDER OR SUPPU:::R PRINTED: 01/25/2005 FORM APPROVED ((;;1 MVL TIPLE CON-STr=~UCTION A. BUILDING B. WING (X;!) DATE .5'URVEY COMPLE,Eb STREET ADDRESS, ell Y, STAI E, ZIP CODE 01/21/2005 INTREPID USA HEAL THCARE SERVICES 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 (X4)JD II PREFIX TAG I I X 071/ Continued From page 2 I approximately 12:30 p,m, confirmed a missed I aide visit the week of 11/29/04and that the i physician was not notified of the missed visit. I I 6, The clinical record for patient # 3 contained II I documentation by the skilled nurse on 12/21/04, ' )' 12/25/04,01105105, and 01/14/05 that indicated i that the visits were missed, The record lacked I , evidence that the physician was notified of the I' I missed visits, I Ii Ail interview with the Administrator and the I I I Director of Operations on 01/21/05 at 10:10 a,m" I j ~:en~~~:j~i~~1a~^J~; ~~ff~~~~t~~~~S~~~~1~ii~j~_~ed J I was' n~t availa'bie, 'H -, ,.--. ,. ,. I X 0731 290-5-38.,09(b) STANDARDS FOR PATtENT I I CARE I I Periodic Review of Plan of Treatment. The total I I plan of treatment shall be reviewed by the I attending physician and Home Health Agency I personnel as often as lhe severity of the patient's I Ii condition requires, but at least once every sixty , (60) days, Date of the review and approval of the , plan shall be documented by the physician's I signature. Agency professional staff shall i promptly aleri the physician to any changes that I' I suggest a need to alter the plan of treatment I I I I I i This Rule is not met as evidenced by: , ' i Based on record reviews end staff interviews, it , was determined that the agency failed to noHf' I I the physician of changes in patient status, failure I I to obtain medication, and missed visits which I I suggested a need to alter the plan of care for 4 of I i 13 patients (#1, 4,5,6) sampled, Findings were: [ I "cHon Report i=':M SUMMARY STATEMENT OF Dt:FJCIENClt:S (EACH DEFIC1Et;/CY MUST BE FRECEEOEO BY FULL REGUlATORY OR LSC IDENTjFYI~~G INFORMATION) JD PRE FIX TAG X 071 X 073 &3~9 PROVJDl::R'S PLAr.., OF CORRt:CTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) I (X5) I COMPLETE I DATE 1 J I , , 1 I I i I I I I Adminlstrator!DOPS will provid~ an inservice ~n .the following: 1102/20/051 1. An inservice will be held regarding when to call till of I changes in patient status and I what parameters are used to identify remarkable findings. ! Staff will be instructed to I include in orders parameters I for reporting B!P and BS on J all patients with diagnosis I of HTN and diabetes. I 24 An inservice will be conducted . I with all professional Staff I when to notify MD of remarkablk "findings duri~g assessments. r Emphasis will be placed on thel timeliness of notification I and accurate documentation. 3. An inservice will be held to review the process for E1D611 If continuaiion sheet 3 oi 5 I II I I I ! . I J I I i ; J I I I i I II II :-11 I , , I II , I State oi Georqia Oiiice oi ReqLllatorv Services V. ~EMENT of PEFIClE/KIf'S ;! LJ..f~ or CORR[CTJ01~ (,Xi) PP.OVIDEP.iSUPPUltP./CLL^, ILloN IlflCA flUN NUM8~H: 092-275-K NAME OF PROVIDER OR SUPPLIER PRINTED: 01/25/2005 FORM APPROVED (X~I I'.lUL TIf'LC OOtIDrrlUCT/Oll A. BUILDING B. WING (X'::\) nA TF SIIR\lF:Y CUIVIi-'U::If:U 01/21/2005 INTREPID USA HEAL THCARE SERVICES STREET ADDRESS, CITY, STATE, ZIP CODE 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 (X4)ID j PREFIX i TAG 1 I , SUMMARY 5T A I EMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) X 073' Continued From pege 3 I i 1. Patient # 1 was admitted to the agency i 03/20/03 with the pertinent diagnosis oi iollowing days: Documentation indiceted that the patient's blood I pressure was 198/107, 168/90, 180/80, 192/88, i 192/92, 180/100, 180/96 and 184/90 on 11/11/04, , . 11/18/04, 11/24J04, 12/27/04,01/14/05, 11/10J04, i 111/24/04, and 12/29/04, respectively. i I An interview with the Administrator and the I i Director of Ooerations on 01/20105 at 4:00 a.m., I I confirmed that the p3tient's blood pressure 'was I elevated and the physician was not notiiied. 2. Patient # 6 was admitted to the agency ior physical therapy services. The start oi care I ::::I~~~~~t ~I~~~~i;~t ~~~;: ~~;~i~;ls~'~~:~~~' I . while urinating. The physical therapist iailed to I notify the physician oi the patient's burning during urination. I I An interview with the .'1dministrator and the I Director oi Operations on 01/20/05 at 3'00 p.m., I coniirmed that the physician was not notified oi I the patient's burning when urinating. I 3. Documentation by the skilled nurse dated I 112/23/04 for patient #4 indicated a new skin tear i on the rightcali measuring 4 centimeters (ems) I I by 3 ems. The record lacked evidence the ! physician was notiiied oitha new wound until i 12/27/04. The nurse also noled the right heel i wound to have a la,ge amount of serous, bloody I i and purulenl drainage with a foul odor present, I I and that the surrounding tissue had a greying I I I ~Cllon Repoll. JRM ID Pr:EF1X TAG X 073 Ugg Pr:OVIDEti:'S PLAN OF COHRECTJON (EACH CORRECTIVE ACTION SHOULD BE CROSS.REFERENCED TO THE APPROPRIATE DEFICIENCY) I (X5) i COMPLETE ) Dr'.TE I I . i documenting missed visits and 02/20/05 notifying MD of missed visits. I Continued compliance will be I monitored by reviewing 30% of I' all medical records for 3 months. Monitoring will be completed bt Administrator/DOPS and Supervi~ors. Five-seven audits will be condticted weekly to ensure compliance I as demonstrated in a timely I fashion. I As c9mpliance is.s~own, monito!ing will be decreased to standard ' i medical review which is 10% . of active' and 10% of inactive I' patient records per month. I I I i i I I , , , I I ! , , i , I I I I I i I I I I I E1D611 If cGl'Itinuation sheel 4 of 5 ....... I i I i I i I I I i , I I I I I , I I I I i I I State ot Georaia Oftice ot Reoulatory Services PRINTED: 01/25/2005 FORM APPROVED - (X3) Dp.rE SURVEY s..,... TEMENT OF DEFICIENCIES (Xl) PROVIDERISUPPlIER/ClIA (X2) MULTIPLE CONSTRUCTION J 'LAN OF CORRECTION IDENTIFICATION I>JUMBER: COMPLETED A BUilDING 8. WING 092.275.H 01/21/2005 NAME OF PROVID=:R OR SUPPLIER ST,;;:EET PDDRi::.SS, CITY, STAT~. ZIP CODE INTREPID USA HEALTH CARE SERVICES 106 NORTHSIDE DRIVE VALDOSTA, GA 31602 , SUMMARY STATEMENT OF DEFICIENCIES I I PROVJDt:.R'S Pu\N OF CORRECTION , (X')ID , , ID i (X5) P REFIX I {Et..CH DEFICIENCY MUST BE PRECEEDED BY FULL i PP.EFIX (EACH-CORRECTIVE ACTION SHOULD BE i COMPLETE: TAG Rt::GULll.TORY OR lSC IDENTIFYING INFORMATION) I 1,4.G I CROSS-REFERENCED TO THE APPROPRIATE I DP.TE i DEFICIENCY) X 0731 Continued From page 4 I X 073 i I color which was a new tin ding. The nurse teiled I I I ; to notify the physician ot changes in the patienl's 1 I ; I wound status. I I I I i I 4. The plan of care for patient #5 tor certification I I I , period 12/11104 to 02108/05 required wound care I I I to include packing with Chlorapactin when , I I available. The record Jacked evidence the I physician was notitiedthat the chlorepactin was I , I I unavailabie during the time period 12/11/04 to I 01/04/05. I i [Interview with the administrator 01/21105 at I I I approximately10:30 a.m. ta-IIed to provide i , ! ;=> lir! r::> i- c> nh <:;"~ \ I r.t"f,,,, :::::t 1+,:", ! - ~\,_enw .h_ _"V_lel__n ~2S n,.J,,~d th___ "._ J Chlorapactin ':',a~ unavailable, which may have I suggested a need 1.0 alter the plan of care. I I i I I I I I "ciion Report ,~M i I 1 I I I I J I I I I I I I I I I I [ I I I , I I I i , I I I I 5~9" elD311 If :::o"tin.v3Iio"n sheet 5 of 5 ! , J I I I I I , I I I I I , I , i I I [ DEPARTMENT OF HUMAN RESOURCES STATE OF GEORGIA LICENSE This is to certify that a Iicen'se is hereby granted to F.C. OF GEORGIA, INC. (Name of Governing Body) to maintain and operate a Home Health Agency w;th 1 branch office\s) (No.) INTREPID USA HEAL THCARE SERVICES named as (Name of Agency) -~._--~-------~~. ----------.--,--..-.'.,- located at ~- 1901 PALMYRA ROAD -- (Street} ALBANY , County of in (CIty or Town) Approval is granted to provide the following services: DOUGHERTY , Georgia Service Area,approved for this agenc HOME HEALTH AIDE, MEDICAL SOCIAL WORKER, NURSING SERVICE, OCCUPATIONAL THERAPY AND PHYSICAL THERAPY. BAKER, CALHOUN, DOUGHERTY, LEE, MITCHELL AND TERRELL COUNTIES. This license is effective'during the period: October 01. 2006 September 30, 2007 thru unless revoked or suspended. "This permit is granted pursuant to the authority vested in the Department of Hunian Resources, by the Official Code of Georgia Annotated Title 31, Chapter 7 and signifies that its facilities and operations comply with the Rules' and Regulations of the Department of Human Resources on the date this perm it was issued." License No: THIS LICENSE IS NOT TRANSFERABLE 047-276-H OFFICE OF REGULATORY SERVICES GEORGIA DEPARTMENT OF HUMAN RESOURCES ~~ 7~~ ~c.~) Interim Director, Office of Reglllatory Services B. J. VValkerl Commissioner Georgia Department of Human Resources . Office of Regulatory Services . Health Care Section . Martin J. Rotter, Director -- Two Peachtree Street, NW . Suite 33-250 . Atlanta, Georgia 30303-3142 . (404) 657-5550 . FAX (404) 657-8934 February 8, 2006 Ms. Suzanne Ryan, RN Intrepid Usa Healthcare Services 2231-J Dawson Road Albany, GA 31707 Re: Recertification Survey Provider No. 117141 Dear Ms. Ryan: Thank you for submitting your Plan of Correction outlining the measures you will be implementing to ensure that deficiencies noted during the Medicare/Medicaid survey will be corrected. The plan is acceptable and will become a part of the record and files of your facility. As the agency with the responsibility for recommending certification, we insist that this Plan of Correction is implemented. A follow-up inspection to determine compliance will be conducted. After a review of the status of your facility, we will determine if you continue to meet the requirements for Medicare/Medicaid recertification. If we can be of assistance during this time, please let us know. Sincerely, ~f~ Ronald Penn, Acting Program Director Home Health Agencies Health Care Section Office of Regulatory Services RP adp DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEf.AENT 0::- DEFICIENCIES 'AND PLAN OF CORR:::::CTION (X1) PROVIDERlSUPPLlER/CUA IDENn::jCATiON NIJM3ER 117141 NAME :Jf p?,:::)\j:~=R OR SUPPLIER INTREPID USA HEAL THCARE SERVICES IX4) 10 ?REFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH D:::FIC1ENCY MUST BE PRECEEDED BY FULL REGUlA.TORY OR lSC IDENTIFYING INfORMATION) GOOD' INITIAL COMMENTS At the time of the survey, the agency was in substantial compliance with 42 CFR Part 484 Requirements for Home Health Agencies as the result of a recertification survey. Standard level deficiencies were cited. G 158 484.18 ACCEPTANCE OF PATIENTS, POC, MED SUPER Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews, the agency failed to follow the plan of care for wound care, a peripherally inserted central catheter (PICC) dressing change, and blood sugar monitoring for 3 of 15 sampled patients (#7,13, and 14). Findings were: 1. The plan of care for patient #14 dated 07/20/05 to 091.17/05 required the skilled nurse (SN) to cover the right heel with a dry dressing. Instead, SN notes dated 21 and 22 July 2005 indicated the SN applied a moist saline dressing to the right heel. An interview with the director of professional operations confirmed the wound was dressed with a moist dressing instead of the ordered dry dressing. 2. The plan of care for patient #7 dated 11/18/05 to 01/16/06 required the SN to change the PICC PRINTED: 12/28/2005 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED f... BU\LDING (X2) MULTIPLE CONSTRUCTION IS. \I\IING SiREET ADDRESS, CiTY, STAT::::, ZIP CODE 2231.J DAWSON ROAD ALBANY, GA 31707 GOOD 12/22/2005 PROVIDER'S PLAN OF CO~RECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFSRENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G 158 G158 Corrective Action: On 01/04/06 a tracking process was implemented to ensure all ordered treatments are scheduled and are indicated on each nurse's schedule weekly schedule. Staff Education: An educational inservice for all staff is scheduled for 01/25/06. Staff will receive written and verbal instructions to review the current POC/verbal orders prior to patient visits and to provide and document care as ordered. Monitoring: Compliance with POC/verbal orders will be monitored weekly by the DOPS and RN Case Managers via case conference with schedule review to ensure all ordered treatments are scheduled and performed. It will also be monitored by the RN Case Managers, OOPS and Administrator through ongoing 100% 60- day clinical record reviews. 01/25/06 Responsible Persons: Staff Nurses, RN Case Managers, Clinical Directors, Administrator (X6) DATE d)-~-OG TITLE Any deficiency state n ending with an te sk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provl sufficient protectio to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days foiiowing the date of survey whether or not a pian of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days'following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORf....' CMS-2567(02v99) Previous Versions Obsalete Event 10: R09U11 If continuation sheet Page 1 of 5 Facility ID: GA1170739 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES [(X1) PROVIDERISUPPLlER/CLlA AND PLA.N OF CO,~RECTION IDENTIFICATION NUtv'IBER: , ! i 117141 ~"AIA~ Or ?RO\lIDER OR SUPPliER INTREPID USA HEALTHCARE SERVICES (X4) 10 PREFIX rAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PREC:::EDED BY FULL RC:GULATORY OR LSC IDENTIFYING INFORMATION) G'158 Continued From page 1 dressing one time a week. SN notes indicated the PiCC dressing was changed 11/26/05 and 12/06/05. The record iacked evidence of a PICC dressing change the week of 11/28/05. An interview with the director of professionai operations on 12/21105 at approximately 3:30 p.m. confirmed the PICC dressing was not changed as ordered the week of 11/28/05. 3. Patient #13 had a principle diagnosis of diabetes mellitus/type II with circulatory disorder. The plan of care dated 12/04/05 to 02/01/06 required the SN to monitor finger stick blood sugars and diet compliance. SN notes dated 6, 8, and 14 December 2005 failed to refiect blood sugar readings. An interview with the director of professional operations on 12122/05 at approximately 9:30 a.m. confirmed the SN failed to monitor the blood sugar readings on 6, 8 and 14 December 2005. G 159 484.18(a) PLAN OF CARE The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury; instructions for timely discharge or referral, and any other appropriate items. This STAN DARD is not met as evidenced by: FORM CI1I15-2567(02-99) Previous Versions Obsolete Event ID: R09Ul1 (X2) MULTIPLE CONSTRUCTION A_ BUILDING PRINTED: 12/28/2005 FORM APPROVED OMS NO. 0938-0391 (X3) DATE SURVEY COMPLETED 8 \\':NG 12/2212005 STREET ADDRESS, CITY, STATE, ZIP CODE 2231-J DAWSON ROAD . ALBANY, GA 31707 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION'$HOULD BE CROSS.REF::RENCED TO THE APPROPRIATE DEFICIENCY) (X5} COMPLETION DALE G 158 G 159 Facility 10: GA1170738 If continuation sheet Page 2 of 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIE:S AND PLAN OF CORRECTION (X1) PROVIDERI$UPPLlERlClIA. IDENTIFICATION NUMBER ,.....U.J,1E 0:= P~O\!IIJE? O?, SUPPLl~K "l'i714<1 INTREPID USA HEAL THCARE SERVICES (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EJl.CH DEFICIENCY MUST BE PRECEEQ::::D BY FULL REGUlATORY OR LSC IDENTIFYING INFORMATION) G 159 Continued From page 2 A. Based on clinical record reviews and staff intenviews, the agency failed to obtain blood sugar parameters for physician notification on the plans of care for 1 of 5 sampled diabetic patients (#2). Findings were: The plan of care for patient #12 dated 11/12/05 to 01/10/06 revealed a pertinent diagnosis of diabetes mellitus/type II. The plan of care required the SN to assess for signs and symptoms necessitating medical attention. Skilled nursing visit notes dated 14, 22, 25, and 29 November 2005 revealed blood sugar readings of 156, 296, 246, and 187 respectively.' However, the plan of care failed to contain blood sugar parameters of when to notify the physician. Intenview with the director of professional senvices on 12/21/05 at 2:20 p.m. confirmed that there were no parameters for physician riotificatioh, B. Based on clinical record review and staff intenview, the agency failed to obtain orders for blood study sampling from the peripherally inserted central catheter (PICC) for 1 of 1 sampled patient with a PICC (#7). Findings were: The skilled nurse (SN) note for patient #7 dated 11/21105 revealed the SN obtained blood for ordered laboratory studies via the PICC. However, the plan of care dated 11/18/05 failed to contain an order to allow blood sampling from the PICC. An intenview with the director of professional operations on 12/21/05 at approximately 3:30 p.m. confirmed the laboratory blood studies were obtained from the PICC without an order allowing blood sampling from the PICC. FORM CMS-2567(02-99) Previous Versions 0:.solel8 EvenllD: R09U11 PRI NTED: 12/28/200t FORM APPROVEC OMB NO. 0938-0391 (X3) OATE SURVEY COMPLETED p.,. BUILDING (X2) MULTIPLE CONSTRUCTION Ii? VJ!NG I ID PREFIX TA.G 12/2212005 STP,eEl ADDRESS, CiTY, STATE, ZiP CODE 2231-J DAWSON ROAD ALBANY, GA 31707 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE A.PPROPRIATE DEFICIENCY) (X5) COMPLETION DATE G159 Staff Education; An educational inservice for all staff is scheduled for 01/25/06. Staff will receive written and verbal instructions and education to obtain physician's orders for ail pertinent treatments including but not limited to: to obtain blood sugar parameters from the physician for all diabetic patients; to notify the physician when a patient's blood sugar is not within the established parameters; to obtain specific orders from the physician to obtain blood from' a PICC or any central catheter. Monitoring; The DOPS is responsible to review 100% all new admissions and recertifications, utilizing the Utilization Review/Compliance Review checklist/worksheet, to ensure all orders are complete and appropriate. Orders will also be monitored weekly by the DOPS and RN Case Managers via case conference to emfure all orders are complete and appropriate. In addition, will also be monitored by the RN Case Managers, DOPS and Administrator through ongoing 100% 60-day clinical record reviews. 01/25106 Facility 10: GA117073B If continuation sheet Page 3 of 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFlCIENCIES AND PU\N OF CORRECTION (X1) PROVIDERfSUPPlIERlCLlA IDENTIFICATION NUMBER: ~~AI:1E 0::: ?~OViD:::::\ OR SU??UER 117~4,1 INTREPID USA HEAL THCARE SERVICES (X4) ID PP,EFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PP,ECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) G 214 48436(b)(2)(ii) COMPETENCY EVALUATION & IN-SERVICE TRAI . The HHA must complete a performance review of each home health aide no less frequently than every 12 months. This STANDARD is not met as evidenced by: Based on employee record reviews and staff interviews, the agency failed to provide a complete annual performance review ior 2 of 2 home health aides (#1 and 2) every 12 months. Findings were: 1. Review of the employee record for home health aide #1 revealed an annual performance review dated 02/23/04. The record cont.,ined an annual home health aide competency evaluation done 09/12/05; however, the record I.,cked evidence of documentation of.,n annual performance review since 02/23/04. 2. Review of the employee record for home health aide #2 revealed an annual performance review dated 03/04/04. The record contained an annual home health aide competency evaluation done 10/04/05; however, the record lacked evidence of documenatation of ali annual perfomance review since 03/04/04. The agency's policy "Clinical Competency" effective date 7/20/01, required the agency to use the discipline specific job description form to document the annual performance review. An interview with the administrator on 12/21/05 at 3:50 p.m. confirmed the agency failed to complete the annual performance reviews for the FORM CMS-2567(02-99)'Previous Versions Obsolele EvenllD: R091J11 t"'t"\Il\l j t:.L.J: I LIL?:J/L.UU: FORM AP?ROVEC OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CUNSTRUCTION A. BUILDING B. V!,NG. 10 PP,EFIX TAG 12/22/2005 I STREET ADDRESS, C!TY, SiAl:::, ZIP CODE I 2231-J DAWSON ROAD ALBANY, GA 31707 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS.R5:FERENCED TO THE APPROPRIJI.Ti:: DEFICIENCY) (X5) COMPLETION DATE G 214 G214 Corrective Action: Both home health aide performance reviews will be completed no later than 01/25/06. Monitoring: A computer calendar monitoring process has been deveioped to ensure timeliness of annual performance reviews and will be implemented no later than 01/25/06. The calendar is reviewed monthly by the Administrator and provides individual alerts to the Administrator two weeks prior to each performance review due date. Responsible Persons: Business Office' Manager, Clinical Directors, Administrator 01/25/06 Facility 10: GA1170738 If continuation sheet Page 4 of 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN Or CORRECTION (X~) PROVIDERlSUPPlIER/CLlA IDENTIFICATION NUMB::=:R: 11714~ :'J...J~E O~ P;:~/Y/!:::::.R OK SUP?LlE~_ INTREPID USA HEAL THCARE SERVICES (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH O:::FICIENCY t"IUST BE PRECE:::DED BY :=ULL REGULATORY OR lSC IDENTIFYING INFORMATIQr\n G 214 Continued From page 4 home health aides. FORM CMS.2567(02-99) Previous Versions Obsolete EvenllD: R09U11 (X2) MUL TI?LE CONSTRUCTION A, 3L!ILDING ! 3. ',:.fiNG I STr~~ET .ADDRESS, ClrV, srp.I::, ZiP CODE 2231-J DAWSON ROAD ALBANY, GA 31707 FORM APPROVED OMS NO 0938-0391 (X3) DATE SURVEY COMPLETED 12/22/2005 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REF;:RENCED TO THE APPROPRIATE DEFICIENCY) Facility 10: GA117073B (X5) C:)M?L;:TION DATE If continuation sheet Page 5 of 5 8. J. V\/alkerl Commissioner Georgia Department of Human Resources' Office of Reguiatory Services" Health Care S&ction" Martin J. Rotter, Director Two Peachtree Street, NW "Suite 33-250 . Atianta, Georgia 30303-3142 . (404) 657-5550 . FAX (404) 657-8934 February 8, 2006 Ms. Suzanne Ryan, RN Intrepid Usa Healthcare Services 2231-J Dawson Road Albany, GA 31707 Re: Recertification Survey Provider No. 117141 Dear Ms. Ryan: Thank you for submitting your Plan of Correction outlining the measures you will be implementing to ensure that deficiencies noted during the Medicare/Medicaid survey will be co rrected. The plan is acceptable and will become a part of the record and files of your facility. As the agency with the responsibility for recommending certification, we insist that this Plan of Correction is implemented. A follow-up inspection to determine compliance will be conducted. After a review of the status of your facility, we will determine if you continue to meet the requirements for Medicare/Medicaid recertification. If we can be of assistance during this time, please let us know. Sincerely, ~f~ Ronald Penn, Acting Program Director Home Health Agencies Health Care Section Office of Regulatory Services RP: adp FORM APPROVEC State of Georqia. Office of Renulatorv Services I N..;r'A~ Or P?OViD?:R 0;:< SU?PU,=R. I (X2) DATE SURVEY . corviPLETED ! I I 12122/2005 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION ,X1) PROV\OERfSUPPlIERJClIA IDENTIFIC.A.T!ON NIJMBEq (X2) MULTIPLE CONSTRUCTION A BUILD!NG 047~276-H I s. \li:~i(; I , 3F~_E:::T ,ADDRESS, 21TY, STAT:>::, ZIP COD':; INTREPID USA HEAL THCARE SERVICES 2231-J DAWSON ROAD ALBANY, GA 31707 (X4)ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULtl.TORY OR LSC IDENTIFYING INFO~MATION) ID PREFiX TAG PROVIDER'S PlAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) . (X5) COMPLETE DATE x 0001 INITIAL COMMENTS x 000 r At the time of the survey, the agency was in I substantial compliance with Chapter 290-5-38, i Rules and Regulations for Home Health : Agencies. The following deficiencies were cited. , i X 0711290-5-38-.09 STANDARDS FOR PATiENT X 07-1 I CARE ! i Patients shail be accepted for treatment on the I basis of a reasonable expectation that the I patient's medical, nursing, and social needs can i be met adequately by the agency in the patients I place of residence. Patients shall not be denied I services because of their age, sex, race, religion, I or national origin. Care shall follow a written plan i of treatment established and periodically I reviewed by a physician, and shall continue under I the supervision of a physician. , X071 Corrective Action: On 01/04/06 a tracking process was implemented to ensure all ordered treatments are scheduled and are indicated on each nurse's schedule weekly schedule. : ! This Rule is not met as evidenced by: ! Based on clinical record reviews and staff i interviews, the agency failed to follow the plan of ',.care for wound care, a peripherally inserted I central catheter (PICC) dressing change, and i blood sugar monitoring for 3 of 15 sampled ! patients (#7,13, and 14). Findings were: I i 1. The plan of care for patient #14dated i 07/20105 to 09/17105 required the skilled nurse. I (SN) to cleanse the right heel with normal saline, I pat dry, using aseptic technique apply Hypergel, i and cover with a dry dressing. SN notes dated I 21 and 22 July 2005 indicated the SN applied a ! moist saline dressing to the right heel after the : Hypergel. Staff Education: An educational inservice for all staff is scheduled for 01/25/06. Staff will receive written and verbal instructions to review the current POC/verbal orders prior to patient visits and to provide and document care as ordered. Monitoring: Co'mpliance with POC/verbal orders will be monitored weekly via case conference and schedule review and through ongoing 100% 50-day clinical record reviews. Responsible Persons: Staff Nurses, RN Case Managers, Clinical Directors, Administrator 01/25/06 i i An interview with the director of professional , ORS lnspection Report AJnV,,;T~ R09U11 (X6) DATE d~ ;;).-O~ LABORATORY DIRECTOR'S OR. STATE FORM 66S9 Ifconiinuationsheet "lof4 State of Georqia, Office of Requlatorv Services .. I'II~ I cu. I Lf.:::tiILUU: FORM APPROVE[ STATEM:::tH OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDEPJSUPPLlERJCLlA IDENTIFICATION NUMBER' IX3) DATE SURVEY COMPLETED (X2} MULTIPLE CONSTRUCTION A. BUILDING ! s. \f.J:!\G _~~. ! S I Kt=l'::T ADDRt=SS, CITY, SiP,T::.. ZIP COc.)~ 047~276~H Nt=<.kE:: or=- rKOViD:;;:R OR 8UP?L'ER I ---1 12!22i2005 INTREPID USA HEALTHCARE SERVICES 2231-J DAWSON ROAD ALBANY, GA 31707 (X4) ID ?REFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFiCIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC ID:::NTIFYING INFORMATION) X 071 Continued From page 1 operations confirmed the wound was dressed with a moist dressing instead of the ordered dry dressing. 2. The plan of care for patient #7 dated 11i18i05 to 01i16/06 required the SN to change the Pice dressing one time a week. SN notes indicated the PICC dressing was changed 11i26i05 and 12i06i05. The record lacked evidence of a PICC dressing change the week of 11 i28i05, An interview with the director of professional operations on 12i21i05 at approximately 3:30 p,m. confirmed the PICC dressing was not changed as ordered the week of 11i28i05, 3, Patient #13 had a principle diagnosis of diabetes mellitusitype II with circulatory disorder. The plan of care dated 12i04i05 to 02i01i06 required the SN to monitor finger stick blood sugars and diet compliance. SN notes dated 6, 8, and 14 December 2005 failed to refiect blood sugar readings, An interview with the director of professional operations on 12i22i05 at approximately 9:30 a.m, confirmed the SN failed to monitor the blood sugar readings on 6, 8 and 14 December 2005. x 290-5-38-.09(a) STANDARDS FOR PATIENT CARE Plan of Treatment. An individual plan of treatment shall be developed for each patient in consultation with agency staff, and shall cover all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, ORS Inspection Report STATE FORM 6699 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS"REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE X 072 R09U11 If continualion sheei 2 of 4 FORM APPROVED State of Georqia, Office of Requlatorv Services STATEMENT OF DEFICIENCIES AND ?LAN OF CORRECllUN (Xi) PROVIDE?JSUPPlIERtClIA IDENTIFICATION NUII/IBER. (X2) MULTIPLE CONSTRUCTION A. BUiLDING (X3) DATE SURVEY COMPLETED 047 -276-K S. \/Vit\G 1212212005 NAl.,',C;: or=- ;:or:;OVIOEi=< OR sup;:JU::::? STREET p.DD?~.SS, CITY, STATE, ZiP COJ::: IX4) ID ?REFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULP.TORY OR !-SC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE Jl.CTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICiENCY) (X5) ::OMPLETE DATE INTREPID USA HEAL THCARE SERVICES X 072 Continued From page 2 nutritional requirements, medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral, and other appropriate items. If a physician refers a patient under a plan of treatment which cannot be compieted untii after an evaluation visit, the physician shall be consulted to approve additions or modifications to the original plan. Orders for therapy services shall specify the procedures and modalities to be used, and the amount, frequency, and duration. X 072 This Rule is not met as evidenced by: A. Based on clinical record reviews and staff interviews, the agency.failed to obtain blood sugar parameters for physician notification on the pians of care for1ot 5 sampled diabetic patients (#2). Findings were: X072 Staff Education: An educational inservice for all staff is scheduled for 01/25106. Staff will receive written and verbal instructions and education to obtain physician's orders for all pertinent treatments including but not limited to: to' obtain blood sugar parameters from the physician for all diabetic patients; to notify the physician when a patient's blood sugar is not within the established parameters: to obtain specific orders from the physician to obtain blood from a PICC or any central catheter. The plan of care for patient #12 dated 11112105 to 01/10/06 revealed a pertinent diagnosis of diabetes mellitusltype II. The plan of care required the SN to assess for signs and symptoms necessitating medical attention. Skilled nursing visit notes dated 14,22,25, and 29 November 2005 revealed blood sugar readings of 156, 296, 246, and 187 respectively. However, the plan of care failed to contain blood sugar parameters of when to notify the physician. I Monitoring: The OOPS is responsible' to review 100% all new admissions and recertifications, utilizing the Utilization ReviewlCompliance Review checklistlworksheet, to ensure all orders are complete and appropriate. Orders I will also be monitored weekly by the OOPS and RN Case Managers via case conference to ensure all orders are c?mplete and appropriate. In addition, it Will also be monitored by the RN Case I Managers, OOPS and Administrator through ongoing 100% 60-day clinical record reviews. Interview with the director of professional services on 12121105 at 2:20 p.m, confirmed that there were no parameters tor physician notification. Responsible Persons: Staff Nurses RN Case Managers, Clinical Oirector~ ,Administrator ' 01/25/06 B. Based on clinical record review and staff interview, the agency failed to obtain orders for blood study sampling from the peripherally ORS Inspection Report ST ATE FORM 5B99 R09U11 Ifconlinuation sheet 3of4 FORM APPROVEC State of Georaia, Office of Reoulatorv Services STATEMENi OF DEFICIENCIES (X1) PROVIDERlSUPPUERJCLlA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PlAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A BUILDING 8 V-l:NG ~ 047-276-H 12/2212005 i':;'.hE OF PROViDE?- OR SU??UER STR;:ET ,.;DD?::SS, CITY, 2Tft.iE, ZIP CODE INTREPID USA HEALTHCARE SERVICES 2231-J DAWSON ROAD ALBANY, GA 31707 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECE~DED BY FULL F;EGULATO;:;':Y OR lSC IDENTiFYING INFORMATION) ID PREFIX TAG PROVID::.R'$ P!....A.N OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE AP?ROPRIATE O:::FICIENCY) (X5) COMPLETE OAT;:: (XL) 10 PR:::FiX X 072 Continued From page 3 X 072 inserted central catheter (PICC) for 1 of 1 sampled patient with a PICC (#7). Findings were: The skilled nurse (SN) note for patient #7 dated 11/21/05 revealed the SN obtained blood for o;dered laboratory studies via the PiCCo However, the plan of care dated 11/18/05 failed to contain an order to allow blood sampling from the PiCCo An interview with the director of professional operations on 12/21/05 at approximately 3:30 p.m. confirmed the laboratory blood studies were obtained from the PICC without an order allowing blood sampling from the PICC. ORS Inspection Report 5T A TE FORM 5899 R09U11 If continuation sheet 4 of 4 ~TATE Of ... ... "- C> ... "- .. C> C> co 'II '" '" DEPARTMENT Of HUMAN RESOURCES GEORGIA ... .. '" '" LICENSE ..., ~ This 10 to certify that a Ilcen... Is hero by II ranted to F.C. OF GEORGIA, INC. (Nahle cfoovllllrnlng 8od1) ., ... .. .. co ... C> .. .. ... named as to malnlaln and operate a Hom.. "'&oUh Agency with 1 branch oIflce(o) -_.~ (N..) INTREPID USA Hi:AL THCARE SERVICES .......---~----.-----. tNoilJT1t orAsren.C)I] located al 3528 CARlEN HIGHWAY. SUITE 201 . IS""') In BRUNSWICK -- (City Of Town I GLYNN . I County of ___.. __.____,.,..". "'..n .. . Georgia ~ '" ... '" c: '" > "- ~ Approval Is granted 10 provide Ihe lollowlng servlc..., NURSING, PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND HOME HEALTH AIDE Service Area approved lor this agenc BRANTLEY, CAMDEN, CHARLTON, GLYNN, LONG, MCINTOSH AND WAYNECOUNnES This license Is ellectlve during the period: December 01, 2006 lnru _._..J!ovember ~~~Q.~?_....... unless revoked Of suspended. "Thls permit Is granted I>Ursuant to the authority vested In.th. Department of Human Resources, by Ihe Olficlal Code of Georgi. Annolaled Tide 31, Chapler 7 and slgnifle. thalli. 'acllilie. and operaUons comply with Ih. Rule. and Regulations ollhe Department of Human Re.ource. on Ihe dale this permit was Issued." llcens. No: 063-277 -H THIS LICENSE IS NOT TRANSFERABLE OFFICE OF REGULATORY SERVICES GEORGIA DEPARTMENT OF HUMAN RESOURCES ~~ ~~~ ~.G, i!l c ... .. Illl,rlm Dlroe:tQf. OH\eG DI RlIllIlllatGry SeNlcfS STATE OF --'l ..... ..... "- o ... "- N> o o CO> DEPARTMENT OF HUMAN RESOURCES GEORGIA '" gj ..... .. '" ... LICENSE ." i=; named 8S This la 10 cartlly Ihal a IIcanaa I. heraby granled 10 ____.. _.__ _____ _..__ __ _ _ __f. C. OF GEORGIA,IN~ _ _ ____ (Nama or Gcvemlnll BCldy~ 10 maintain and operata a Home Heallh Agency with 1 branch 0Illce(5) {No.I"-- INTREPID USA HEAL THCARE SERVICES '" ... N> N> CO> ... o .. '" ... (Hame or Agency) Iccated at 3528 DARIEN HIGHWAY -_._-~.__.,. (Slr.ct. ._.__In BRUNSWICK tClty or Town) ,Countyol _... GLYNN I ( :'~~ll qi;I, ... ~ ... '" <:: ~ "- ill <:: Approval Is granled 10 provide Ihe following service.: _ HOME HEALTH AIDE, NURSING SERVICE, OCCUPATION_~.!:. !.H.E~!,!,.,_~!,YSIC I~L 2~ERAPY, AND THERAPY Sa Nice Area approved for thl. agency BRANTLEY, CAMDEN, CHAAU01l, GLYNN, LONG, MCINTOSH, AND WAYNE COUNTIES . This Ilcenlels .""cllve during the period: _pECEMBER 1,2.005 thru NOVEMBER 30, 2006 ..._ unlas. revoked or sUlponded. "Thll permit Is granted purauant 10 Ihe aulhorlly vesled In lhe Oap,H1manl of Human Resources, by the Olflclal Code of Georgia Annolaled Title 31, Chapler 1 and .lgnllle. lhallts facllllte. and operations comply wllh Ihs Rule. end Il.sgulallona of the Oepartmenl of Human Resource. on Iho dal. thIs permltwasjs!oued." THIS LICENSE IS NOT TRANSFERABLE llcen.e No: D63-277-H OFFICE OF REGYLATORY SERVICES GEORGIA OEPARTM ENT OF HUMAN RESOURCES ~~ -Zo-~~~~ I...uln~otnelll V ........ ~I'~ -'" @:: ~I L. . ,.,> 4 - - Dll"lCu::lor, ource of ROGulac1:lry S'INICIS .~- ,..."'1111I".' i!'i c ... .. 11/0112006 WED 13:50 FAX 912 261 0397 INTREPID USA/BRU- OCr-17-200a rUE 09:41LaH,DHR-ORS HonE CARE UN-I'F FA)j--Nf},4Il44ffil&1 IgIOO< P; Q3 ;~~M~NT OF DEFICIENI:IES .,c, "!.AN OF CORl'ECTlON (X1) PRO~IOCIl/SUPPUERlCLl~ ICENTIFlCA1l0N NUMBEl'l: (X2) MULTIPLE CONSTRUCTION A oUILDING a. "",NO By .~~ of GeorQia Office of Rl!l ulatoServices ~oJCi O~J.277 -H "-ME OF f'ROVlOER OR SOPPLIS'< $TF!EE'l' AOO~e.SS. CI'T'Y, STATE, ZIP CODE 3528 CARlEN HIGHWAY, SUITE 2D1 SFUJN5WJCK, GA 31520 !NTREPID USA HEAL THCARE SERVICES (l:411D PReFIX TAC> SuMMARY s,.ATOMENT OF DEFICiENCIES lEACH DEFICIENCY MUST BE PRECE~ED OY FUlL RECUlArORY 01< lSC IDENTlPfING INFORMATION] 10 PREFIX TAG FROVlDEf\'S pl.Jl;N: OF' CORREctiON (EACH coRRECTIVE AC1l0N sHOU~D BE CROSS-REF~CEO TO TliEI'PPROPRIATE DEf'ICIENC;1') (lC~ !:.DMPlSTIi Cl^'Te x 0 INITIAL COMMeNTS x 000 At the time of the survey, the agency was in sUbstantial compliance with Chapter 290-5-35, Rules and Regulations for Home Health Agencies as the resu!t of a state licensure inspecflon_ The following deficien eles were cited. At leasl qu~rterty, appropriate health professionals representing at least the scape of the program, shall review a sample of both active and clased clinical records te assure thai established policies are followed In providing seNices (direct services as 'Nell "s se~s under arrangement). Evidence of this review shall be dOC\Jmented by dated minutes. The adrnirlistrator will assu,re that all 9/18/06 group ofprofessional personnel meetings are documented, dated and maintained for esch quarterly meetin as per agency policy #1.002 (anached . The administrator will be r",,!,onsible for monitoring ongoing compliance by participating in preparation and documentation of each quarterly meeting. X os 2.9D-S.'3S-.07(8)(b) ADM1N1STRATlVE X 059 STANDARDS This Ruie ;s not met as evidenced by: . Based on re~ieW of agency documentation and staff interview, the agency failed-to maintain clocumentatian of dated mInutes of all Group of Professional Personnel meetings for the year 2004. Findings were: Review of the Annual Total Program Evaluation for the year 2004, completed 03/02105. indicated the Group of Professional Personnel met four (4) times a year. The 2004 Annual Total Prcgrom Evaluation revealed that the advisory group (group of professional personnel) meeting datl;s were 03/10/04,04/22104.07/22/04, and 11/23104. During an interview on 08/17/06 at 10:00 a.m_, the admlnlstrater presented PI/PAC (grollI' of professional per50nnel per administratOr) I meeting rTlinutes to the sUNeyor dated 11/18104 i k!!' ~he year 2004. The administrator eonfirrned , I"~~ IRl>pedign p,~-,~ ~ n ./ . ~~_;l..~~ ~'1j.u;.-'l ~ ~..1-;-.:::~-. .t::=i!.:-:;=': :~ ':'"1:;- :~,,;-.'...., TlTLf I '~)OA~ l..!Q/!, ' .._---:--=-:.-~.~~'~'~. .~.~~'.:.:- ....~....__. ._. .---'-.---' '-'- .~_.__.._- , " --- -.-.-.'--" ..--...-- .-----.-."- -- .- 11/01/2006 WED 13:50 FAX 912 261 0397 INTREPID USAlBRU 141002 .-.----..-..-.--.-~'--..'--..~.--____~~TCr'l'nel~._ FORM !'PPROVED ! ". :"'_'~-':'- -"'~-'~'--'--, re:JJlr'::?-__._~_.~_ , STRE.;::j ADDRESS. CfTY, STATE, ZIP cooe 3528 OARIEN HIGHWAY, SUITE 201 BRUNSWICK, GA 31520 State of Geora'a. Office of ReQulatorv Services I . i STA,So.i::NT OF CiE::rC:=:NCiE.:: i AND PLAN Of co"'" H. "nON 1(;;,. ;:::r1r-'.....lfi;::U.sti;:;;:::II~P.Ji:ti-' i I!:'!~~.,.,;:"-=-~Tl':"',,' ~!l.l~~!!'~t;l; uu';'._, _-. NAME OF PROVIDE? OR SUPPUEK INTREPID USA HEAL THCARE SERVICES (:<4)/0 I p~eFlX J TAG I I X 059 i Continued From page 1 I that, at the time of the survey, she was unable to locate any other PUPAC meeting minutes for the year 2004. SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICJE:NCV MUST BE; PRECE.eOeo BY FlJLL REGULA TOrty OR LSC IDENTIFYING INi"ORMA. iION) j :X~~ ~.<!Ul~!!,!..~ ':-,-,"'l:iH':)('TIo~'f\i l."t,-:,:!:",;:- ~Uf?";:T J '- -~. Z6~?i.ET~~- A-, .r~ ,...... _..0 ""t"."..::.i.i\.l;:' I PR~FIX I TAG I , I X059 PROVIDER'S PLAN OF CORR.ECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCeo TO THE APPROPR'A TE OEFICIENCY) f CO~~5T~ I OAr; I , X OS9 290-5-38-.08(e) SCOPE OF SERVICES X 069 Coordination of Patient Services. All personnel providin~ services shall maintain a liaison with the Home Health Agency to assure that their efforts effectively complement one another and support the objectives outlined in the plan of !realrnen!. The dinicai record shall contain dated minutes of case confarericc~ -waOiying that effective interchange, reporting, and coordinated patient evaluation does OCcur. A written summary report of clinical and progress notes for each patient shall be sent to the attending physician at ieast every sixty (SO) days and upon diseha,>!e. A copy of these reports shall become a permanent part of the patient's clinical record. This Rule is not met as evidenced by: Based on clinicai record review and staff interview, the agency failed to send 60 day summaries to the physician every 60 days for 5 of 9 patients (#2, 3,8, 14 and 16) who required 60 day summaries. Findings were: I 11. ReView of the djnical record for patient #2 revealed e 60 day summery of care dated r 07120106 for the time periOd 05/26/06 to 07124106'1 I The area on the form which indicated that the j summary was faxed Or mailed to the physician failed to ccntain a data I During an interview on 08/16106 at 5:00 p.m., the rl admjnisiTat~r and director of operations failed to conflnm that the 60 day summary was sent. A fax , GRS InSpectIon RepOI! STATE FORM .- - --- ..-----. ..-- ---.. The administrator will assure that coordination of patient services occurs for each patieDt and will assUl'l that a writteD summary report. for each patient is sent to the attending physician at least every 60 days by reviewing with an staff policy 2.005 on care coordination and teviewing items to be included On the summary; instructing all skilled and office staff on internal process to include, when to write the summary, what should be included on the surnmaxy and who will send the summary to the physiCian. The Director of Professional services will monitor camplianceby reviewing all 60 day summaries for 2 months, ensuring the summaries have been sent to physician end documented as such. 9118/06 Ongoing compliance will be I monitored monthly through tier I I clinical record review process and I the 60 day billing audit. Each clinical ! record =iewed will be monitored I to ensure that the 60 Qa Y summary was preparoo and sent to the attending, : physician, These 2 processes ! '''' ';-;':'i.1-1 !f=::-::i..l:<ilicr::;,",:eCi l..Ji;2 -.__.__n.._____. ----- -.--- ----,-..... .,-. 11/01/2006 WED 13:51 FAX 912 261 0397 INTREPID USA/BRU .._-- .~--_._-._-, .-- .-----PRINTE6'" 08/'3012006'- FORMA?PROViOD State of Georoia, Office of Reaulatorv Services L ! i ;~.~T;t:7;"~;-~~O=~t~~~~I~:::.f i~~, ~~o~~~~~~~~~;~r~~~~ I 063.277.ii NAME OF PROViDE;; o?. SUPPlIi:K INTP-E'PIO USA HEAL THCARE S=RVICES (X4) 10 I' SUMMARY STATEMENT OF OEAClENCleS I ~P.eF()( (l!AC~ DeF IOoNCY MUST Be PRECeEoeo BY FUll. I TAG !=\EGUlATORY OR LSC IDENTIFYING INFORMATION) I r X 0691 Continued From page 2 . I confirmation presented to the surveyor on I 08/17/06 indicated the Summary was faxed to the physician on 08/17/06 at 9:17 a.m. /2. Revi~w of the clinical record for patient #3 ievealed a 60 day summary of care dated 0711 0/00 for the time period 05/12/06 to 0711 0/06. The area on .the form which indicated that the summary was faxed or mailed to the physician failed to contain a daie. During an interview on 0S/1.6/06 at 5;00 p.m., the administrator and dii"ector of operations failed to confirm li1at the 60 day summaI)' was Sen t A fax confirmation presented to the surveyor on 08117/06 indicated the summary was faXed to the physician on 08117106 at 8:07 a.m. 3. Review of the clinical record for patient #8 revealed a 60 day summary of care dated 07104/06 for the time period 05l0S/06 to 07/04/06. The area on the form which indicated that the summaI)' was faxed or mailed to the physician failed to contain a date. During an interview on 08/16106 at 5;00 p.m., the administffitor and director of operation failed to confirm that the 60 day summary was sent A fax confirmation presented' to the surveyor on 06/17/06 indicated the summaI)' was faxed to the I I physician on 08/17/06 at 9:19 a.m. 4, Review of the clinical record for patient #18 I revealed a 60 day Summary of care dated 07112/06 fcrthe time period 05/17/0610 07/15/06. The area o~ the form which indicated that Ihe I summary Was faxed or mailed to the physician I faiied to conlain a date. I During an interview on 08/17/06 at 10:40 a.m.. I I . , OR:S Inspeetlcn Report STOrE FORM - .'.._- -"...--- .-.'.-----. : ~ ~l,i!L~~I,7- r:o ... ~ :.:": : I (JQ, ML'1."iiPi.E CCJNSTRUCTlON 10 I .~,x I X 069 :\ 1~,_ 1 ~ Il!i 003 ; il~, ?:- r~ ~_~~I:\' PROVIDeR'S PlAN OF CORR ECTlON (eACH CORAe:CTIVE ACTION SHOUl..D BE CROSS-REFi::RENCEO '1"0 TH~ APPROPRIA re DEFICIENCY) repreSent approximately 40-50% of all charts reviewed monthly. . Any chart found out of compliance will be corrected immediately. ._ ..';.:n" ",-:= . .. -.- - .-____ n_._ I- sm.. ADDRESS, CITY. STAT<. liP CODE 3528 uARiEN HiGHWAY, SUITE 201 BRUNSWICK, GA 31520 0911712006 I (X5I . COMPLETe. ...r. I I I I I ; I I I i ! ; 11/01/2006 WED 13:51 FAX 912 261 0397 State of Georljla. Office of ReoulatoTY Services ! ! i: ~,~~.T;~;~t!;?;g=[;~~!E;~!F I ;;,.,. ~~~:~2~~~~~P~I~~c;~l^ I 063-:;71 -H NAME Or PROVlDEr{OR SU?PUi;:"" INTREPID USA flEAL THCARE SERViCeS (X4l10 f PREFIX I TAG I X 069' Co~for,ued From page 3 I the administrator and direclor of operations , presented a fax confirmation to the Surveyor which indicated the summary was faxed to the physician On OBJ17/06 at 8:54 a,m, SUMMARY STATEME;NTOF DEFICIENCIES (EACH OEI"ICJ ENCY MUST BE PRECEEO!D BY FUll RE':;ULATORYOR LSC IOENTr'YtNG I"'FORMATlON) 5, Review of the clinical record for patient:t 14 revealed the lack evidence that the physician had been sent a BO day sUmmary tor certification period 06/01/06 to 07/30106. An interview with the administrator on 08116106 at 16:-40 p,ffi, COnfirmed iac~ of evidence of sending 60 day summary to the physician, X 071 290-5-3<3-,09 STANDARDS FOR PATIENT CARE Patients Shall be accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patients place of residence. Patients shall not be dElnied services because ofmeir age, sex, race, religion. Or national origin, Care shall follow a written pian of treatment established and periodically reviewed by a physician, and shall continue under the supervision of a physician, ' This Rule is not met as evidenced by: A Based on clinical record review and staff interview, the agency failed to perform weights as ordered On the plan of care for 2 of 5 sampled patients (#5 and 7) who required weights. Findings were: f 1, The plan 01 care dated 07119/06 for patient #5 i required the skilled nurSe ( SN) to weigh the ORS Inspection Report STATE FORM ..'W -'._- ----. --- ...------.--. INTREPID USA/BRU I4!J004 "-,----~--... ._-, -----p-R1J'1TB1'lllfI3llnOOS- FORM APPROVED , i ii\2) MUi...Ti?~ C;vl~~7?iJCTrOI" j !., pi.il~.f"lt'.b:-_ : ,;.~~; 9~~;.~;~::;~="" I I' PR~FIX I TAG I' i I X 069 I PROvrD~'S PLAN OF CORRECTION (EACH CORR.ECTIVE ACTION SHOUl.O BE CROSS-REFaRENCi;:O TO THe APPROPRIATE DeFICIENCY) ; :. .r."~:- 1""-- STREET ADDRESS, CITY, STAlE, ZIP CODE 352B uARIEN HiGHWAY, SUiTE 201 BRUNSWICK, GA 31520 X 071 The administrator will assure that all care follows a written plan of Care established and periodically reviewed by a physician by ill servicing all skilled staff clinicians all following thel plan of care, writing change orders as received and accurately and completely documenting care. The director of professional services and/or de.ignee will monitor ongoing compliance by reviewing all skilled notes, as they are turned in, for accurate and complete documentation of following the plan of I care for a period of2 months then the i administrator will re-evaluate for need I of continued 100% review, If compliance with plan. of care policy is I Jeos than 90% durillg this 2 month period, 100% review will continue,for i another 60 days and all clinical starr , .::!:l':;L~i 08/17/2005 I COM~f I DA,. j ! 9/18/06 "---.-.,., '-"--.- --"---~'...._-------_. 11/01/2006 WED 13:52 FAX 912 261 0397 INTREPlD USA/BRU State of Geor.~ia. Office of ReQulatorv Services I ZTl,7.'EtJ.!::!-';: (.',~ L'::r=IG!';:;:-~C!E~ L~~; PROVju~FJSd;t~'LlE~/C:U.:o i ;"r.lG rLAN ui"' COF:P...c.CiION 'rtJE!'ITI~IC4TI"N' lJU~"'a~Q' ":.l.,;, ~~:_ ""'--... ,~i. j NAl.,.,E OF PROVlDE-P. OFt SLJP?UiCFi. INTREPID USA HEAL THCARE SERVICES -._-- "-._-~-.. 411 005 .O....ClhlT:;p: ~~'lf2.~c..a.s--... FORM APPROVED . ~'V'''''''' ! E. ;r~~~J~ j ~"12'. UUL T\F~e '-:'7'''lSr=.I)j:-7tO~ I ;XS; DATi; SU;=;\;cY COMPL:::TED SrrtE~ I ADDRESS, CITY. STATt:, ZIP CODE 3526 DARIEN HIGHWAY, SUITE 201 BRUNSWICK, GA 31520 iX4110 I SUMMARY STATEMENT OF OEFICIENClES PREFIX i (~CH O~ICIENCY MUSTSe PP.ECEEDEO BY FULL TAG REGULATOR'fOR LSC IOENT\Pf1NG IIIlFORMATlON) , X 071 Continued From page 4 patient every visit and report to the physician a weight variation of 2 to 5 pounds. The SN note dated 08108(06 lacked evidence of the weight was done. An int!;rview On 08/16/06 at 5:00 p.m. with the administrator and director or operations confirmed that the weight was not done on 08(08106. 2. The plan of care dated 07f07106 for patient #7 required the SN to weigh the patient every visit and notify the physician of a weight variation of2 to 3 pou.nds. The SN notes dated 17. 25, and 28 JUly 2006 lacked evidence that weights were done. During an interview On 08/15106 at 4:30 p.m.. the administrator confirmed that the SN failed to obtain weights on the above dales. B. Based on Clinical record review and staff . interview. the agency failed to assess blood sugar results as ordered on the plan of care for 3 of 7 sampled patients (#6, 12. and 17) who required I blood sugar assessment. Findings were: 1. The plan or care dated 07/0BlOO for patient #6 . required ~he SN to assess the panent for abnormal biOOd sugar (8S) levers. The physician I was to be naMed of a blood sugar greater than 350. The SN notes daled 07/;2106 and 07/27/06 I lacked evidence of BS Jevels. . I A11 inl!;rview on 08/15(06 .t 2:05 p.m. with the I administrator confimned thel the SN failed to I assess the BS levels On 07112106 and 07/27/06 I 2. The plan of care dated 06f.l0(06 to 08128/06 I OP.S 1,.,$pectlCl!'i i\e,ooti: STAn:: FORM DO< I PR~FIX TAG I I X071 ! I I PROVIDER'S PlAN OF CORRECTION I (5ACM CORR.CTlYE ACTiON SMOUUl BE I . CR.OSS-RE:FER!NCED "0 TH E: ACPP.OPRlA TE . . i oeFiclENC'I) I will be re-educated on following the I nlan of care and documenting the sarue. Ongoing compliance will then be monitored by sampling at least 20% of ~] clinical notes submitted each week. I I I i , I I I i I I J.1.!.i....11 ;i '~Al[fnlO2iioo": <:r:.",~ ':: ~~ '-: ----.-.~---- ..----- ,;c/']7/2\;(;6 CX5) COMPliTF! OAIi 11/01/2006 WED 13:52 FAX 912 261 0397 INTREPID USA/BRU lo!J 006 ..._----. "---... I : ~!,~';.~~';~?! .?=!:_~~C!~~~i=:~ State of Georaia, Office of ReQulatory Services ~ ,- i'RINTED: OSl30120QR FORM APPROVED , I i;;, "II ?RO'vivBii5UPPLIEnJClll=. ~ ~ .- -. ~ i i r:t21'MULTIOLE' CQNSTCj II"':"!O,,\I i l tX3l ~~,:,f ~~~.~.E y .~- . - , . ~'.::::_: ~. .... n. ~"._ !"::....,.....,,,"'" j i:.. .;;i;'.~ I 08/17/2006 I I 063-277_H 1 NAME OF P~OVIOE" o~ SUPPUER I INI;<;:PIO USA IiEAL TI'iCARE SERVICES STREET ADDRESS, ellY, STATE. ZIP COOE 3S2S OARIEN HIGHWAY, SUIT" 201 8RUNSWICK, GA 31520 (X4llD I' PREFIX TAG I SllMMARY STATEMeNT OF DeflCIENCfES (EJ.CH DEFICieNCY MUST BE PReCEED2T) BY FUl..L REGULATOR.Y OR LSC IOENTlFYING INFOFuMTlON) I PR~FI>( ! TAG I I I X071 I "~O\llDER'S PlAN OF CORRECiJON (!;ACH CQAAEC~ ~T10N Sl-iOUlD ae CROSS-RE;:FERENCEO 10 THE APPROPRfAiE DEFICIENCY) I IX," I COMPi"ETE OATi ! I X071 Continued From page 5 for patient # 12 with pertinent diagnosis of diabetes mellitus required the SN visits 3 times' a week mr 8 weeks; SN to notify physician of 85 less tha 60 or greater than 250. The SN notes failed to reveal evidence of patient 8S Dr physician 'notification on 3, 5, 7,10,11,14,19, 21,28.31 of July and 4, 9,11, 14 of August SN notes. , An interview 08114/06 at 14:00 p,m. confirmed that the SN failed to assess, perform, or notify physician of BS levels according to the plan of care for the above dates.' 3, The plan of care dated 07114106 to 09/11/06 for patient #17 with primary diagnosis of diabetes mellitus required SN visit 2 times a week tor 8 weeks to include BS monitoring and assessment to report BS less than 60 or greater than 250. The clinical record lacked evidence of as monitoring on 15, 18, 22, 25, 29 of JUly Or 01, 05, 08 of August,,2oo6. Additionally, the clinical record ,"';ked evidence of PICC line dressing change on 08108106. An interview with the administrator on 08/17/06 at 10:45 a,m, confirmed that 88 monitoring was not performed on the aOOv" dates, As well as, failure of the SN to perform Pice line dressing change on 08/08/06. , X on! 290-5-3a- 09(a) STANDARDS FOR PATIENT 1 CARE /1 Plan onreatment. An individual pian of lleatment shall be developed for each patient in cOnsulta!icn with agency staff. and shall cover all pertinent diagnosis, including mental status, types I 0: ~ervlces an~ equ~m,~nt lequir:o, fr~quency of I I vrsrts, prog,osrs. :-e.,ab,rrmtion pOlential, I I XD72 I The administrator will assure that 19/18/06 an individual plan of treatment shall I be developed for each patient in I consultation with a.,<>ency staff, shaH I include all required items and other I I appropriate items by in-servicing all ! ! skilled siaff on 'Writing an Effcctive ! ORs Inspection Report STATE; FORM .--.--. -.---.-.-. .---.",-----. -----. 11/01/2008 WED 13:52 FAX 912 261 0397 INTREPID USA/BRU iglOO? ~---.._- -- -----._---.......--. '------'--------p;:iiNTED: 08r.J0120oe- FORM APPROVED i.t..=;.l!~;~.~ ] ... '~~'.'~ i' ......." STn.cE:T AOOfU::SS, CITY. STATE, ZIP CODE 3528 OARJEN HIGHWAY, SUITE 201 BRUNSWICK, GA 31520 State of Georoi.. Office of Regul"lorv Services ! I i :C:T.A'r~Me:N~ (".~ ;-,;:o=-,,-'rli:"Mr",;;~. Ii ~i", ;._ko.......-..."v"i.o.".E_~~,._SV_., pu....~,;"..U,"~:.l_IA... I ~,,.,,9P~t.I\;al:"-~op-~~~.;!.~;.;- _ _ .h i 063-277_H NAME: OF PROVIDER OR: SUPPIJE? INTREPID USA HEAL THCARE SERVICES (X4) ID I PRE."'IX TAG I I x 0721' Continusa From page 6 functionallimilations, activities permittea, nutritional requirements, medications and. treatments,safety measures to protect against injury, instructions for timely discharge Or referral. and other appropriate items. If a physician refers a patient under a plan of treatment which cannot be compJeted until afier an evaluation visi~ the physician shall be consulted to approve additions or modjffca~ons to the origina/plan. Orders for therapy seNices shall specify the procedures and modalities to be used, and the amoun~ frequency, ana duration. SUMMA~Y STATEMENT OF DEFICIENCIES (EACM Ol;FlCll;NCY MUST ee PR!!CEEOEO BY FUll R::OULATORY OR LSC rOI;NTlFYING INFORMATION) This Rule is not met as evidenced by; Based on Clinical record review and' staff interview. the agency failed to obtain wound' care orders and blood SUgar parameters to trigger physician notification for 2 of 1 g sampied patien'" (#12 and 19). Findings were: 1. The ciinical record for patient # 12 revealed dressing changes by skilled nurse On 07/28, 31 and 08/04, 09 to the right knee. There were no physician orders for dressing change to this area, An interview with the administrator on 08/14/06 at 4:00 p.m. confirmed that there Was not an order On the plan of care tor dressing changes to the a bove area. I i 2. The plan of care dated 07/31/06 to 09f26/Q6 ! I for patient #1 g with primary diagnosis of diabetes mellitus laCk&d parameters for blood sugar (SS) i moniloring. I An interview with the administrator on 06/17/06 at I 0900 a.m, confirmed the pian Of car" laCked I 'R.s Inspection Report TAT;: F'ORM ttl:~ -"--',--... I I j r:Q, MlJlTlflLE CONSTRUCTION 1 i~[ DATE SURVEY .' ".-t.- :--::" ........... -- -~ , 08/17/2006 I PR~FIX I TAG I X072 I PROVIoeRs PlAN OF CORReCTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REfERENCeo m THE APfJROPfUAllr OEFlCIENCY) i rxS) I COM?f.c.li;: OAT!, I CMS 485". The Director of Professional Services and/or designee will monitor ongoing compliance by reviewing all Plans or care to include change orders for a peri od of 2 months then the adrniniSlrator will re-evaluate for the need of continued 100% review, If Compliance with plan of care policy is less than 90% during this 2 month period 100% review will continue for another 60 days and all clinical staff will be re-educated on following the plan of care aIld documenting the same. Ongoing compliance will thenJ be monitored by sampling at least 20% of all eMS 485' s submitted eac r week. . I I I I ! I I Jt1.-.11 " .::.. .~. ,,~~.. .. ---- .--------.""'---.-- --'"--"-'- - ____. __u __. '__."__ ____ .--- ---'--......-.. 11/01/2006 WED 13:53 FAl 912 261 0397 INTREPID USA/BRU '-----"'-" -----pRINTED; 0813012006 -. FORM APPROVED State of Georcia.. Office of ReoulatorY Services , I i ~.~;T;t1~N~;-1~~;.~~~~I~!"~ i\~': ,~.~e;~~.~.i2:~.~:~~~~~~~. r iJitj -277-M i OG!j MlJUiPU= C;ON5T?.!JCTIGN ! A ~l'JLD!'''''G I;:. 1M",.::, J ' STREE, ADORESS, CITY. STAre. ZIP CODe 35Z6 DARIEN HIGH1i>'AY, SUiT" 20j BRUNSWICK, GA 31520 I 1011 008 ; I ;'~J IJAT=. .$1J1o(\,.'EV . "'.!.,,:,'t"-:o.. . -- --. I 10 I PROVIOERS PlAN OF CORREcTION I IX~I PREP'IX (EACH CORRec-nve ACTION SHOULD Be COMPLETE TAG CROSS-REfeRENCED TO THE AP PRDPI<IA TE OA,tE DeFlcIENC'rj I X 072 , I , NAME: OF PROVIDeR ~ SUPPLlfP. INTREPID USA HEAL THCARE SERVICES 1X4) 10 I FREFIX TAG SUMMARY STATEMeNT OF DEFICIENCIES (EACH DEFICII<NCY MUST BE PRECEEOED BY FUll REGULATORY o~ LSc IDENTIFYiNG INFORMATION;! X 072 Continued FJ:Qm page 7 evidence oi BS parameters X 073 290-5-3B-.D9(b) STANDARDS FOR PATIENT CARE X 073 The administrator will assure that the total plan of treatment shall be reviewed by the attending physician and shall promptly alert the physician to any changes that suggest a need to alter the plan of treatment by I in-servicing all clinical staff on noting changes in patient condition, who to report 10, when to report to physician and documentation of notification. The Director of Professional SClVices . and/or designee will monitor compliance by reviewing all communication notes and any documentation of notification to physician for a period of 2 months the 1 the administrator will re-evaluate for the need of continued 100% review. I reviewed results are 90% or greater compliance, ongoing compliance will be monitored by sampling at least 20~ of all clinical notes submitted weekly to detennine changes in patient's condition that might warrant a change in the plan of care. I I I j ! i , ! Periodic ~eview Df Plan of Treatment. The total plan of treatment shall be reviewed by the attending physician and HDme Health Agency personnel as often as the severity of the patienfs conditiDn requires, but at least Once every sixty (60) days. Date of the review and approval of the plan Shall be dOClJmented by the physician's signaiure. Agency professional staff shall prompUy alart the phYSician to any changes that sU\lgest" need to a~er the plan of treatment. This Rule is nol met as evidenced by' Based Dn Clinical record review and staff interview, the agency failed tD nofify the physician of a patieot fali and a new wound for 2 of 19 sampled patients (#2 and j 2). Findings were; 1, The physical therapist (PT) nole dated 08114/06 for patient #2 reffected that the patient's caregiver stated the patient ended up on the 1100r While trying to pull up clothing, The PT note indicated "no significant injury, some bruising of the elbows trying to crawl to the chair." The record lacl-:ed evidence the physician was notified of the incident. During an inlerview on 06/16/06 at 5:00 p.m. with the administrator and directDr of operations, the administraior confirmed the physician was not notified Dflhe patient's fall. The administrator elso confirmed that it Was the agency's expectation that the phYSician oe notified of aU patient falls. ClRS In~pecuClI1 Repofi SiATE FORM ~~SlI L~41_1 \ ---------....-..- --- ._-.._---._~----_... 08/17/2006 9118/06 .:..;:.-,'" 11/01/Z006 WED 13:53 FAX 91Z Z61 0397 r {}::; ~ ~~~~~::~J~~'~:.~~7:~~~i;:. , 1153-277 -n INTREPW USA/BRU il!I009 ..----.-- -'.-. --PRlm'l:lF08f.30I2QOe'"- FORM APPROVED I ,(;Q; MULTlPu: Cur41'?iJCIION I . [;i~; ?=~~ S~::J:~E';' 1 , i !Il" 8tJILD!~J~'- ; ~_ l'\~hl,? J ~al1712006 INTREPID USA HEAL THCA.~e SERVICES I I STREETAODFtESS. ClTY,STAlc,Z1PCODE: 3528 OARIEN HIGif,VAY, SUiiE 201 I BRUNSWICK, GA 31520 (x.IID SUMMARY STATEM<HT OF DEFICIENCIES I "REFIX {EACH DEFICjI!NCV MUST BE ~RECEEDeD BY FULL TAG REGULATOR.Y OR LSc JDENllFYING INFORMATION} X 073 i ConU~ueCl From page 8 I I 2. During recore! review for patient #12 the SN I documented performing wound care without notiiyir'9 tile physician oi wound located on right knee. . . . An interview with the administrator on 08/14/06 at 2:00 p./Tl. confirmed the SN iailure to nomy the physici:;n oi wounCl On right !<nee. X on 290-5-38-.09(d)1 STANDARDS FOR PATIENT CARE Clinical Record:;. 1. A clinical record shall be established and maintained on each patient in accordllnce with accepiE!d professional standands and shall contain: (I) pertinent past and current finding:;; (u) plan of treatment; (iiQ appropriate identifying information; (iv) name of physician; (v) drug, dietary, lTeatment and actMty orders; (vO signed and dated dinical and progress notes' (clinical notes are written the day :;ervice is rendered by t!te providing member of the heanh . team and inconporqted no Jess allen than weekly); (viQ copies of Case conferences; (vfii) copies of summary report:; sent to the physician; and (ix) a di:;chiUge summaI)'. I This Rule is not met as evidenced by: I Based on clinical record review and stail . inierview, t"le clinical recorCl failed to contain I I documentation of physician notification, blood :;ugar values, wound healing and a SO-day I summary tor 5 of 19 sampled patients (#7, 8, 10, I ORS Inspodion R.port STA To FORM W" '--.- "'--'-"---'.-- --. .--.-----.--.-. -~'--. .~----_..-. .- 10 I I'FlEF/X . TAG I PROVlOElts PIN< OF CORRECTION lEACH COAAEC11\IEACTION SHOULD ee Cp.oSS-REFEIlEHCfo TO THE ~PRO~RIATE DEFICIENCY) X 073 X 075 The alimini.trator will as:;ure that a clinical record containing pertinent past and current findings in accordance With accepted profes:>ional standards is maintained for every patient receiving home health services by in-servicing all agency staff on appropriate and required documeartation for the clinical Tecord. The Director of Professional Services or designee will monitor ongoing compliance by performing 100% clinical ~ord review on all patient records for 2 months then the administrator will re-evaluate for the need of continued 100% review. If the plan of care policy is less than 90% duri.ng this 2 month period, 100% review will continue for another 60 days and all clinical staff will be I re-educated on following the plan of care and documenting the same. I Ongoing compliance will be monitored By sampling at least 20% of ail clinical ,. notes submitted each week. i ~;4L'1 ': ":":-::.:.:~.;.;- .r."" I c""~. DATE I I I I 9/18/06 J 11/01/2006 WED 13:53 FAX 912 261 0397 of Georoia. Office of ReQulatorv Services ; :"....TE~r:"''T ':'l~ D~F'h:.!e~r.::!!;~ i &I'lD alAH or ~!'!"O~':"T1,:,,!'" I ~.~~~~ ~.iO.2:~~~~?:.=r:.~~~~~~;:. I uo,:)-27; ~H NAMe: Of PROVlOEn OR SU?PUEJt INTRE!>IO USA HEAl.. THeME SERVICES lX4) 10 I PREFIX I TAG I SUMMAl\V STATeMEIfr OF OEFICIENCIES (eACH DEACIeJ'lCV MUST Be PREcEEDED BY FUU R!:-GULATORY OR LSC IDENTIFYING INP""""'TlON) INTREPID USA/BRU 1t!I010 .-- '-' -o>RlJ'ITE!T:lJll:I3ll/2O"ae- - . FORM APPROVl>D Ii^~, ~~~ 3i~ir'::' I 10 I I PREFIX I TAG I I PRO\IIDER'S PlAN OF CORRECTION (EACH CORREcTIVE ACTION SHOULD BE CROSS-REFl!RENCeD TO THEAPPRO?RlATe DEFICIENCY) I X 075 CD~tinued From page 9. X 075 11. and 16)_ Findings wens: ; , {;GJ MUL 11,.1.c. C.D"SiRUCTI~N :::.. SUlL~hr~..; : ~. N\f!!>I-'::_ " -- STReeT ADoRESS, CITY, STATE, ZIP coDe 35za DARlEN HJGiiWA Y. SUiTE 201 BRUNSWICK, GA 31520 /1. The plan of care daled.07/07IOS'for patient #7 required the sl<Jlled nurse (SN) to weigh the patient every SN visit and to report a weight variation of 2 to 3 pounds. The-initeJ weight recorded en the inita! cOmprehensive assessment dated 07107/06 was 110. The SN note dated 07/31/06 indicated a weight of 112 and the SN nOle dated OSI04/06 indicated a weight of 114_ At the time of the survey the notes lacked evidence that the physician was notified of the weight variaton. An interview on Oat15106 at 4:30 p.m. was conducted with the administrator and director of operations to determine if the physician was aWare of the weight gain. At that time, the administrator confirmed thalthe physician was not notified of the weight gain. An interview on 08117/06 at 10:50 a.m. with the administrator and director Qf operations revealed that the SN communicated the weight gain to the physician; hOWever, the SN failed to document the communication in the clinical record. 2. A physician's Order daled 06122/06 fer patient I f#j required the SN to visit 2 times a week fer 1 week, then 1 time a week for 1 week for wound I care to the right (R) upper arm. The SN note I dated 06/30/06 lacked evidence WOUnd care was provided 10 the (R) upper arm.' , I , An interview On Oat16106 at 5:00 p.m, with the I I adminislmtor and director of operations reveaied I that the (R) upper arm wound had healed; I however. the administrator confirmed that the SN I failed to document that the wound had healed_ I . ! 3. Review of the ciinical record ior patient #11 I. OF{S Inspec:non P.epon STATe FORM ~, ';'~~i_ i'j ~.......- ...k....... ...... ....... .._- -.------.. ---'--~- -'-.--. -_ "0.__._. .__ _ .__ __. 08/17/2006 I (X5) C"""""E OAiE I I , I I I I , i i ., I ! ! 11/01/2006 WED 13:54 FAX 912 261 0397 INTREPID U5A/BRU I/!JOll -.'----...---- R.--.-----:--..-'..-~II"fI~O.UO/.j~-- FORM APPROVED State of ! STflo.'!'EM!;N"! a~ ~~!=!!::=~!~~f ! !..~.Ii:" ~!..t'l; :'~ ~':"=-~~~-l':"" I.... -_~.~__~_..__..__._. o' j "'" ~~'~~!~:-~"~~:"".\.;r::-:~,;~- i ii2j i';VLTIF't.E ':"0N~T?vCTI;;.;r.; ! !)'~; !,)p. TE' SUR\JE'-' I -=-.'JP..ft'l~=-=!' INTREPID USA i-iEAlTHCARE SERVlCE:3 !.l:._ ~'.!ILUiNG , J;: \':J1i'J(:, I I STi!E<T ADDRESS. cm. STATE. ZlP CODE i 3526 DARlEN HIGHWAY, SUITE L01 BRUNSWICK, GA 31520 (X4l'O I SUMMARY STATEME/iT OF DEFICIENCIES '. I III I PROVIDER'S PlAN OF CORRECTION PRTAEi'O-lX I {","eH DEFICIENCY MliST Bl! PRECEEDeD BY FUll I' PREP", I (EACIi CORREcTIVE ACTION SHOULD ef RE';UlA TORY OR Lse 100>I11FY1NO INFORMATION) TAG CROss.REFERE>leEO TO THE APPROPRJATE I DEflCIENCY) X 075 i Continued From page 10 II X 075 I Ilaci(ed evidence of a SO-day summary OT care for . I the tims. period 04/14106 to 06/12106. During an int~rview on 08l1S/0S at 3;30 p.m. ,,!ith the adminisllCltor and director of operations, the /. administrator confirmed that the SQ..day summary of care for the time period 04/14/06 to 06112106 had not been done. Late entry documentation of the 60..cJay summary <lated 08117/06 was proyided to the surveyor on OS/1710B. A fa){ confirmation was also providea whlcn indicated the 60 day summary was sent to the physician on 08117/00 3t 1D:10 a.m. . ~. --._... --'"-'.---. 06J~~77 .i1 ) (j8/17/2006 NAME OF PROVlOc~ O~ SUPPUEn. I i>!l I COMPlETe DATE I I I I 4. The plan of care dilted 0711 SI06 for patient #16 required the SN to notiIY the physician or a blood sugar value greater than 350 and under 60. The SN notes d aled 1. 3, and B August 2006 Indicated the blood sugar was greater than 200; however. the S N failed document the bloOCl sugar value. An interview on 08117/06 at 10:40 a.m. with the administrator and director of operations confirmed that the SN iailed to document the blood sugar value. 5. The pliln of care dated 05f04106 to 08102106 for patient #1 0 required the SN to assess bloOd sugar levels on each SN visit after next SN visit beginning 06/15/06 report BS findings to the . physician. Although. BS logs were maintained in I I the home there were no documentation in the SN notes that the SN assessed or reported findings to the physician. . I An intervi~... with the administrator On 0811712006/' I. at 09:00 a.m. confirmed thet the SN failed to I document Dr report BS levels to the physician. OR.S Inspocoon Report 5T A Ti: FORM m; I I ; ~i4!...1! Ii .:~!"!:i''';~ll-::- :~;:";- -0 ...--.. ---. ._---..-._~-_._--_.._-----_.. 11/01/2006 WED 13:54 FAX 912 261 0397 INTREPID USA/BRU 14!I012 ;~;i\i7~;:'. 0Oi3i11ZOtJI;j"--' FORM APPROVED tale of Georoia. ffj e oi Reoulatorv Services I ST....T:Mcri7 OF CrErU~JEr'iCf!~ j AND Pl,AN OF C.QRM:E' :::TII'J~ ; :-~.. ~P'ry.~'!DEP'..:SU!=lP'.:E?Jcu.e. I '':'l=t.r.!~'~e~~!-: "1.':5:~ 1......,."._... _ ~....,._.. .___ i v...::; \1.....:'1"'1..= ...(..'I"l';';:'''';~L .I~IC l""'"n,,'I"s.<:lIo...e:v ! .. ...- ~~~VP~~~~" . (X4) 10 I PR!'.FIX ! TAG , i I I I I STREET ADDRess. cny. STATI;.lI~ CODE i 3528 DAP..!EN HJGHWA Y, SUITE 201 BRUNSWICK, GA 31520 SUMMARY STATEMEIfT OF ceFlCIENCIES i 10 PROVIDeR's P...... OF CORRECTION (EACIl DEFICIENCY MUSTae PREceEOED ay FULL I pp.eFrx (EACH CORRECTIVe ACTlON SHOUUl Be F!fGL.'l.ATORY QI:t LSC IDENTIFYING INfOP.MAOON) TAG CRDSS-REFEReNCI!DTO THEAPPIltOPRIATe DEFICIeNCY) I I \jO:S.~i'1-x !~ o"'j~",u ! E; ;,-.qr"G._ NAME OF PROVIDER OF. SUPPLIeR i 08117/2006 INTREPID USA HEAlTHCARE S~RVICES I lX5J I CO~PLEi~ DAre I ! ; I , I i I i i i i I I I I I I I , i i I / I ! i JRS InspeciiOl\ R.eport STATE FOMI ..., 4':'~~1 ~. ~~!"'::;t::l'!.~:. ~"'f';1 "; ." ,.~ - .--------... .--.-- .... .-.--- -- -....... 11/01/2006 WED 13:55 fAX 912 261 0397 INTREPID USA/BRU " __l)l;Hh'U!Jti rUt U9:41l An DHII-GRS HOllE C~t~NIT ,JBX NQ, 4044637184 I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FO MEDICA ole D SERVICES ;!lENT OF DEFlCIEIIClES !lCn PIlOVlOI!RIsuPi'UERIr:LIA " ,'LAN OF CORRECTION IDEImF1CAllDN NUMllElO: MUl111'LE CONSTIIUCTlON A, fllJlLDING S. IMNG 117144 NAME 0' PROVIDER OR SUPPUER INTREPID USA HEAl.1lfCARE SERVICES C;X4)IO , PfleAx, TAG SUMMARy STATaI1I!NT OF OEFIClfNali$ tOACH OBFlClE"CY MUST SE ""ECEEIll!O BY FULl. REGUl.ATORY OR LSC I<JBN11I'Y1NG If'IfURMATlOH] 10 PRI!l'Ix , TAG I G 000 INITIAL COMMENTS GOOO G 121 Allhe ijme of the sUNey, the agency was in substantial compliance with 42 CFR Part 484 Requirements for Home Health Agencies as !he result of a partial extende~ recertification SUNey. The fallowing defICiencies were cited, 484.12(e) COMPLIANCE WI ACCEPTED PROFESSIONAL 5TO G 121 The HHA and its lOlaff must comply with accepred professional standards and principle.li that apply to profeliSionals furnishing services In an HHA. Thi$ STANDARD is root mel as evid"nced' by: Based on record review, staff inter'oliew, policy review, and home visit observation. the home health aide tailed to loUaw the agenc.y's poijcy for administratiDn of a bed bath ror 1 of 1 sampled paijent (#4) who required a bed bath. findings were: G 145 The agency's policy and procedure, "Bathing and Grooming", required the bath water 10 be changed at /east once during the procedure. During a home visit observation with patient #4 on 08/16/06, at approximately 09:00 a.m., the horns health aide failed to change the water at least once during the bed bath. 484. 14(g) COORDINATION OF PATIENT SERVICES G 145 A written summary report for each patient is sent to the attending physician al 'east evary 60 days. This STANDARD is nol met as evidenced by: STfiEET ACDFI'ESS. ctTY, STATE, 3528IlARlEII tUGHWAY, SUITE 2.1 BRUNSWlCl<. GA 31520 PROVlOER'S PIJ\H OF CORP-SCllDN (EACH cORRB:Tl\ll! ACTlOOI SHOULD ,S cRoss-RSFEIIEIICEO TO THI' APPROPRIA T. OEFICIENCY) The AdIDinistrator will assure'that the HHA and its staff will 'comply with acceptl:d professioual standards and principles while fimrishing service:< by in servicing all staff aD following comp8l1ypolicy and procedures. ,In-service will include Dotirig the location of aU P & P manuals in office noting the location ofRobYLl Rice "Home Health NUTSing Procedures" manual ilIstructions to sraff on usio g the manuals and following procedures issuance and review ofthc "Bathing IIDCl Grooming" procedure to all aides. The Director of Professional Services Of designee will ensure thi1t eat;h h health aide has reviewed the protocol (or proper bathing and documentation of slllI1e is in their personnel file. Director of Professional Serviees or desigllee will visually monitor ongoing cotnplianc~c;ompetency by observing each HHA giving a bed bat to ensure appropriate procedure is followed and same will be document and placed in each IiHA J personnel file by - '0 JO-,,/ 0 b ' 17.1) .~ I -rrl I 141015 p, 02 lXS1 caMPl,e'l'I(IH o.o.r~ ~ Le/Ub IdJ06J! I l,61'SU& I .ASCAATOAy DIR.l!CTOR'S ClR PROvtOIiRlSUPPLJER ~l;PFlesePltJliT1VE'S SfGNATU~E TITLE , ~ xkPl.~ ' ." I ."1 .I :M.-. _ . \:. .. jcien~ atatemenL en-fing h !'In qm'I~1t :-, de;JQtr.;'3 ;; d~d""r.~ Ulhi~h th$lo i...~t!""::i,:,- ...~:.-~:? ,,:=~:.::!.t:d ~::: =:-:-:;=~;; ;.1:'~~';~-":: :; :.; _..i,:..,..:,1Vi ~'.91 ~h~i~~~~~~;: r~~;~~:.~~~~~~)~:~~~~~ ;C:~;;~i ~::-:.:~~ ~.:~~~~t:':;~_~: ~~:~e;.~'..~~ .:~~~~~ ~~;.:\~7-- ~~;:~~'~:;:~ 7;~~':~ :~~:;~.~"::. _~:-'~'" ~~~ ~:~~::~,.~~,.~~~.: ,:::;1: '.:.,ic'f1l.lV ~-:;:; .;:;;].~ (t1Uoll. ';~C'...rn{mts ar6 m.atJi& ,avaitaoic to tf1.a tacilit-./. ff aeiieI8"ciP.s <In= r;ite':! ~"""l'Jrl)V",rj r:-ra" -;;f :-:~-:;:<":";~ ~'!r;!::o;i!," :';': .::::"":1.1,,;::',~ ,:,:;;r.;;,:,,: i'ciii".::p.;il..::,'I. 'OF!M c.~-~sa"!OZ""') Ftevlcw VlIlralona ';lJsd4tl!! e.-err.la: 4;t.lp F::::IAIY 10: G1\1170N;. !f ~~{\til'lUit!..r. 'Sl':aat P::!ge .~ of 12 11/01/2006 WED 13:55 FAX 912 261 0397 ----t:1EFA;:' 7;vicj~i 0f HCAL l1'l7\i'itTRtll\lIIWSeRVlcEs CENTERS FOR MEDI ARE & MEDICAl SERVICES SfATEMENT OF DEFICiENCIES . (l(1) PROvIOEFlIS(lP.\.IERICt". ~ .60Nc. r-i.AN OF t;1)~Rfr:-r!Of,; i l~...'jiFJo:-~l:Tl,=*" Ht"f.Age~ ! ..":'?',~ NAME OF PROVl('EI'I 01'1 SUPpe'ER INTREP:D USA iiCALTHCARE SeRViCeS (X'l'C I PREFIX i TAG I . SUMMARy STAT<MENr OF CEFlCtENCJES ll'.ACH CEFICISNcy MUST BE PllECl<1!Del> 8Y FULL REGULATOIlY OR LSC lOEl<TIFYlNG INFORMATION) G 145/ Continued From page 1 Based on cflnieal record review and staff interview, Ihe agency failed to send 60 day summaries to the physidan every 60 days for 5 of 9 patients (#2, 3, 8, 14 and 18) who required 60 day summaries. Findings were: 1. Re'"iew of the Clinical record for patient #2 revear;ld a 60 day summary of care dated 07120106 for the time. period 05126106 to 07/24/06. The area On the form which indicated that the summary was faxed or mailed to the phYSician failed t'J COntain a date. During an interview on 08116/06 a15:00 p.m., the administrator and director of operations failed Iu confirm that the 60 day summary was sent A fax confirmation presented to the surveyor on 08/17/00 indicated the summary was faxed to the physidan on 08117106 at 9:17 a.m. 2. Revl9w of the dinical record for patient #3 revealed a 60 day summary of care dated 07/1 0/06 for the time peIiOd 05112106 to 07/10106. The area on the form which indicated thai the su'mmary w;ls faxed or mailed to the physician faired to contain a date. During an interview on'08l16(06 at 5:00 p.m., the a<lministrator and director of operations faRed 10 confirm that the 60 day summary was sent A tax /' confirmation presented to the surveyor on 08/17/06 indicated the summary was faxed to the )' physician on 08/17/06 at 9:07 a.m. 3. Review of the cflnicalrecord for patient #8 I revealed" 60 day summaty of care dated 07/04/06 for the time period 05/06/06 to 07104106. I The area On the form which indicated that the I INTREPID USA/BRU I(!J016 COU,ITJ;"n. "p~n~cs:... FOP.M APPROVEO OMS NO. 0113 39 . {Y2J fAt.It TIP!.f CONS1"RUC'TJC~J , !6 ~!..lH.OI~ ~_..-._-... _.....""'r'~~;;.. -"---.-. .. ~!?: \~AN:" ...;- /STREET A.ODRESS. CITY, STAlE, ZIP COOE 3528 OARlEN HIGHWAY. sUITe 201 . j BRUNSWICK, GA 31520 10 I PROVlOOll'S PlJIN OF CORRECTIOIf PREAx (EACHCOl'lP~C~VEACnoNSHOVlOBE TAG I' CROSS-REFEReNCED iO THe APPROPRJATE . DEFICIENCY) , G 145/1 The administrator will assure that a written S1.lmIIlaIy report for each patient is sent to the attending physician at least every 60 days by reviewing with all staff policy 2.005 on care coordination and :reviewing items to be included on the summary; instructing all skilled and of:fic~ sraff on internal process to include, when to write the summary, what should be included on the sllInmIlIy and who will send the summazy to the physician. The Director of P:rofes~ional Se:rvi.~es:WI monitor I compliance by reVlewmg all 60 day summaries for 2 months, ensuring the summaries have been sent to I physician and documented as such. . Ongoing compliance will be monitorl monthly through the tier I clinical . record :review process and thc 60 day billing audit Each clinical record I re\7iewed will be monitored to ensure that the 60 day summary was prepared I and sent to the attending physician. These 2 processes represent I i approximately 40-50% of all charts I reviewed monthly. Any chart found OUI I' of compliance will be corrected . immediately. . I I ...... ~ ""~.... ~ ... o;t:; . I, ",,:-.Jv,," . I ll<Sl I COM.LETlON I DAiE I 9118/06 I I FOR,M C!l.lS-2:36i(Q:!.99t Previous V~i01l$ ObsOJelEl Event 10: 041"U1 Fac:IttyJO' GA1170i3i. If cQntinIJ2tion sheet P~ge 2 qf 12 --.-..----------- --.-,----.- 11/01/2006 WED 13:56 FAX 012 261 0307 . -t.1El"I\IfrMEN'r"ClI' I'I!:1\CT1'tJl.ND1'ftJTvIArI ::il::KVIt;t:;:, CENTERS FOR MEDICARE & M DICAID SERVICES INTREPID USA/BRU I4!lQ17 '---'--' OQ''''I'TC''''. ~n,""c FORM APPROVED OMS NO. 093 -0391 t('x.'!~p=.,,!.SU~'f r i J'..JM"'~.eu i STATEMENT OF OEFlcrENCIE$ i !l."J[l;:)lJ'.1Ii .:llt ':-O?'<~Cpr)"1 I 0(') i'~OVlOEPJSUP?lIE.ruCt..,~ J j!:€:!'.'~!Fl~.T!O~ !'t:JM!f~ .. , .V,I/I NAME OF PROVIDER OR SUPPUER STREET AOORESS. a;y. STATE. ZIP CODE INTREPIQ iiSA HEAL ,HCARe SERviCES 3528 OAR/EN HIGHWAY. SUITE 201 BRUNSWICK. GA 31520 (X4110 i SUMMARY STATEMENTOf' IlEFJCIENClEs I 10 I PRoVIDER'S PlAN OF CORRECTION I COM~'ON PFlEfIJC . (EACH O~FIClENCY MUST BC PRECEED€O BY FUt.!. PREFIlC (eACH CORRECTIVE ACTION SHOULD BE TAG I REGULATORY Oll LSC 100000FYING INFORMATION) I TAG . CROSS-P.EFERENCED TO THgAPPROPRIAT! DATE i DEFICIeNCY) I I , , , i G 145! Contirued From page 2 i i I G 145j I I I I summary was faxed or mailed to the physician ! , I . failed to contein a date. I I I I During an interview on 08116/06 a15:00 p.m., the I adminkstrator and director of operation failed to confirm that the 60 day summary was sent- A b c;onfirrr.ation presented to me surveyor on 08/17106 indi<;aled the summary wes faxe~ to the physician On 08117/06 at 9:19 a.m. 4. Review of the clinical record ior patient #18 revealed a 60 day summary of care dated 07/12/06 for the time period 05117/06 to 0.7115106.. The area on the form which indicated that the summary was faxed or maHed to the physician failed to contain a ~ate. ., During an interview on 08117106 at 10:40 a.m., I the administrater and direcfDr 01 operations presented a fax confirmation to the surveyor which i11~icated the summaI)' was faxed to the physiciam on 06117106 at 8:54 a.m. S. Review 01 the clinical record ibr.patient# 14 , revealed the lack evidence that the physicien had ; i been sent a 60 day summary for certification I I I period 06/'J1/06 to 07130106. , I An interview with the administrator On 06116/06 at I I. I 16:45 p.m confirmed lack of evidence of sending I I 60 day sU/';1mary to the physician, . , G 1551 I G 155 464. 16(a) ADVISORY AND EVALUATION / I J FUNCTiON I I i I I I 'P,7<:,4..; . !Xl) tJYL TIP!..! CO/'~STRt.;CT)ON , ,~ !!1.!!L'l!"IIJ I r ~ ifJl:.:~ ~s-"- '200S ;=ORM CMsoo2Sa7(02-9S) Pr&\riolJIS. VertOris ~ Event 10: .1&Ln F;;I~IO: GAnroi'3A rfcon:;nuation q:heet Page 3 of 12 - --.-.------.--- '-'-.- .._--. 11/01/2006 WED 13:56 FAX 912 261 0397 INTREPID USA/BRU 1/lI018 ut:~"" I MEI'f'. U~ Ht:AL I fl~",".N "t:rtVIL.t:S--- CE RS FOil MEDICARE & MEDICAID SERVICES S'rA'f"EMENTOF OEFfCIEHr,:lf$ j (l(11 PRO\AOeRlSlJP~ueR1CllA ! .'j.lt) Pt~jW ~ ':'OP.R::-:-'IO"! f jr'CM'''r:"..t;T1t'''11.1 NJI',;~;::;' I I -,..... .. -. .-...-,. PRIN'Tiin- rnll:'1OO(lf"l.l=: .--- FORMAPPROVEO..... OM8 NO. 0938-0391 ~..:, ,;,-........ , NAME OF PROVlOEri OR SUPPLIER STREET ADDRESS. CITY. STATE. zrp COOE iNTREPiD USA iiEAL.THCARE SE~V'CES 3528 DARlEN HIGHWAY, SUITE 201 BRI.INSWICK, GA 31520 (X4)IO i SUMMARY STATEMENT OF OfFIClENCIES I Jl) J PROVIDeR'S Pl.AN OF CORR!Cl1ON I "'II PREFIX I (EACH DEFICIENCY Must BE PRECEEDEO ay Full. I PIlO!X I (EACH COMECTN< ACTION SHOlJl.C BE COMPLEi10'" TAG REGULATORY OR lSC 10eNTlFYING INFORMAnON) TAG CROSS-AEFERENCSO TO THE APPROPI\IA TE . DAt'E , . I OEFICIENG'/) I G 1551 Continued From page 3 I G 155/ The adminislIator will assure that all I ; 9/1 8/06 group of professional personnel The group of profeSSional personnel's meetings meetings are documented, dated and are documented by dated minutes. maintained for each quarterly meeting as >ler agency policy 1f1.002 (attached). This STANDARD is not met as evidenced by: The administrator will be responsible Based on review of agency documentation.and for monitoring ongoing compliance by Staff interview, the agency failed to maintain .part;icipating in preparation and documentation of dated minutes of all Group of documentation of each quarterly Professional Personnel meetings for the year meeting. 2004, Findings were: ! Review of me Annual Total Program Evaiuation for the year 2004, completed 03102/05, indicated the Grollp of Professional Personnel met fu!lr (4) times a year. The 2004 Annual Total Program Evaluation revealed that the advisory group (group of professional personnel) meeting dates were 03110104,04/22/04,07122/04, and 11/23104. During an interview On 08/17106 at 10:00 a.m., I the admi~istrator presented PIIPAC (group of professional personnel per administrator) meeting minutes to the surveyor dated 11/18104 for the . year 2004. The administrator confirmed that, at the time of the survey, she was unable to locate any otller PIIPAC meeting minutes for the year 2004. G 1581484.18 ACCEPTANCE OF PATIENTS. POC, G 158 The arlministrator will assure that all 9/18/06 MEq SUPER . . ll:8re follows a written plan of care I I c' . II . I' bl" h' ! established and periodically reviewed I are 10 ows a Wlillen p an or care esta IS eo I I by a doctor of medicine, osteopathy or i and periodically reviewed by a doctor of medicine, I osteopathy, or podiatrie medicine, I I podiatric medicine by in servicing all I skilled staff clinicians on following the I This STANDARD is not met as evidenced by: I ' plan of care, writing change orders as I r received and accurately and completel~ . I ;;''14-/= ~ IY.1) UUl ~~ o:bN....~lJc!!~ I r h. BUILDrNG I i:: l~nN~ .P(2} DATE SVP.VE'! . ':;CMI"LEiE~ --....._-- ,,:p;. '''':'.7r::''',~ FORM CM5-250i(0W9~ Pravi.)US Versions: Ob$o!cte Event rD: d14111 ~8dlity 10: GAn7012A, lieontinuation shee: Page 4 of 12 11/01/2006 WED 13:56 FAX 912 261 0397 '. . 'ut:,..~ I McN I U~ H!:Al. TRf!JilIJ'FlU~t:KVJc..;t:S-- CENTERS FOR MEDICARE & MEDICAID RVICES , STA TEIJIENT OF DE ~CIENCIl!~ I ~N'" on oi.'" r""l':: -"'f'lClc.CI~""""I"l ,....... u, ,. '......_..,.. ,~'l PRc.'."OERfSUPP1l2R1ClLa. I .nr;:o.lT'Cfl"'O.,.......Il.I...'l.4Q"a. , -_..... '-'. ..... ........... ..~11~~ NAME 0;: PROVIOE~ OR SUPPU~R iNTRE?iO USA HEAL. THCARE SERViCES IX4)ID I' PREFlll TAG I I SUMMARYSTATEMeNTOFOEF1CIENCIES . (EI.C~ DEFICIENCY MUST BE PRECEEOED BY FUU RE';uu. TOllY OR ~SC IDEHTIFYlNG INFORMATION) G 158 I I , Continued From page 4 I A. Based on Clinical record review and staff interview, the agency raned to perform weights as ordered on the plan of care fer 2 of 5 sampled I patients (#5 and 7) who required weights. Rndin~s were: 1. The plan ofeare dated 07/19/06 for patient #5 required the ski/Jed nUlae ( SN) to weigh the patient every visn and report to the phYSician a weight varialio.n of 2 to 5 poundS. The.SN note dated Oat08106 lacked evidence of the weight was done. An interView on 08/16/06 at 5:00 p.m. wnh the administrator and director of operations coniirmed that the weight was nol done on 08/08106. 2. The plan of care dated 07107/06 for patient:J required the SN to weigh the patient every visit and notff( the physician of a weight variation 012 to 3 pounds. The SN notes dated 17, 25, and 28 July 2005 lacked evidence that weights were done. During an interview on 08/15/06 at.4:30 p.m.. the administrator oonfirmed that the SN failed to I obtain weights on the above dales. B. Based on clinical record review and staff intelView. the agency failed to assess blood. sugar I results as ordered on the plan of care for 3 of 7 sampled s:atients (#5, 12. and 17) who required I / blood sugar 'assessment. Findings were: 11. The plan of can! dated 07/08/06 for patlent #5 ! requln!d the SN to assess the patient for I abnormal blood sugar (6S) levels. The physician was to be notified of 2 blood sugar greater than I 350. The SN notes dated 07/12100 and 07/27/06 I ; FOJ:\M CMS.2Sa7{02~) Pn!";OU$ Venh0t\4 ObaoIlNt E:...rnIO: 4tHt11 '--"'-.-- ---....-.--- .__ __N INTREPID USA/BRU 11I019 OQINT~r'l' OA.r:tnr.Uln~__ FORM APPROVED OMS NO. 0938~391 !l(3l OA TE SURVEY :':o~F':..rrro , (X:2) MOL !1.ColE C0MS~tJt;TION i.A. 9!JrLO!"IG ;=- '.~'!'NG ;;S;l~j':OGt STm:i!r ADDRESS. CITY. STAT;;. ZIP CODE 353 DARrEN HIGHWAY, SUITE 20' BRUNSWICK. GA 31520 10 I PROVIDER'S PLAN OF CORRECTION PREFIX I (EACJ4 CORRECTlVE ACTION SHOULD 8E TAG CP;;OSS-Rcr=c:~CEO to mE APPROPRIA"i'C; DEFICIENCY) G 1581 documenting care. The director of ' professional services azul/or designee will monitor ongoipg compliance by I .evieWIng all skilled notes, as they are turued in, for accurate and complete documentation of following the plan 01 care fo. a period of 2 months then the administrator will re-evaluate fo. need of continued 100% review. If compliance with plan of care policy is less than 90% during this 2 month period,. 100% .review will continue fOE another 60 days 3lld all clinical ~taff will be re-educated on following the ; plan of care and documenting same. . Ongoing compliance will then be monitored by sampling at least 20% of all clinical. notes submitted each w.eek . I. IX!) I CO~~ON , I I I I I , I I I I I J Ij continUation sl1eel Page 5 Qi 12 !=ad~'t'; j<:; G.;11'i'(i7SA 11/01/Z006 WED 1~:57 FAX 81Z Z61 0~87 INTREPID USA/BRU .--t1U'AnT"iE:~~', 0F nu,L Tn i'tl'ltrfjtJ1\ll7\.. "'t:t(VIL;!:S---.~---.--.-. CENTERS FOR MEDICARE & EDICAl SERVICES , STATEMENT .o~.o~F1<:.~~C!ES iAND PlA/Il(Il" !.\')'t'fcl.._oI"", I ':~; T~~ NAME .oF ?RoVIO:R DR SUPPU<R lNTRfp:lD USA H~TnCARE SERVICeS (leO) 10, .' SUMMARY.STATEMarT .oF OEFlClENCleS PREFIX , (EACH DSFlCIE>!CY MuST as PRaCEeDBl BY FULL TAG i RI'!GUtATOR,Y OR LSC 'OE~T1F't'ING INFORMATION) G 158 i Ccnli;;ued From page 5 Ilac~ed evidence of 8S levels. An intelView .on 08115/06 a12:05 p.m. with the administrator confirmed that the SN failed to as5eS>l the BS levels on 07/12/06 and 07/27106. . 2. The plan of care dated 06130/06 to 08128106 fer patient :I' 12 with pertinent diagnosis .of diabetes mellitus required the SN visits 3 times a wee~ for 8 weeks; SN te nctifY physiCian of 85 less Iha 60 Dr greater than 250. The SN notes failed to reveal eVidence of patient BS .or physician notification on 3, 5. 7, 10, 11; 14, 19, 21,28, 31 of July and 4, 9; 11, 14 .of August SN netes. . An interview 08114/06 a114:00 p.m. confirmed that the ::iN failed to assess, perferm, .or nati1Y physician .of as levels accerding to the plan .of care fer the above dates. I 3. The plan .of care dated 07/14106 to 09/11/06 for patier.l #17 with primary diagnasis of diabetes meUilus r~ujred SN visit 2 times'a week fDr 6 I weeks to include 8S mcnitering and assessment to report as less than 60 .or greater than 250. The clinic3/ record lacked evidence .of as . monilering on 15, 18. 22. 25, 29 of July .or 01, 05,1 08 of August, 2006. Additionally, the cJinicai reCOrd lacked evidence or PICC line dressing I change on 08108/06. I I I An interview with the administrater on 08/17/06 at I' 10:45 a.m. confirmed that as menltering was not periormed on the above dates. As weq 2S, failure I oill1e SN t.J perform Pice line dressing Change i en 08/08/003_ I , FOR.M CMS-2567(02.99} F'rcllio~~ Y\!!rs101'l5 Db$ofets c~t1C;'='':~lil I/!IOZO J (X2) MlJ'.. TI?L.E ~ON~TP.UC"'ON i J,,: e'JILDING __'__ ______.___ ~. DQII\JTcn- fUlnnf?OO!_ FORM APPROVEiD OMS NQ..0938-0391 !~: ~:re SURVEY '" ':C:';;lt~~ I I P':F~ I I TAG I G 158/_ , I I I I '? :.II,~'-J:;: I I , I I I I I STREET ADCRl;SS. CITY, STATE. liP cooe 3528 CARlEN HIGHWAY, SUITE 201 BRUNSWICK, GA 31520 PROvulER's PlAI; .oF caRRecTlOll (EAC~ cCAAecnve ACTION S>iOUlO as CROSSeRE=~"ENCED to THE APPROPRlAT! DeFIOENC\') 0a,r;;i;ijiji. i [X$I I COMIUTION j D"T;' , I I I- I I i I I Ifc:onrlnuation ShClvt Pag~ is of 12 Facificy 10: GA1ti073A "..-- ---.-.-..-.--.-.----.- -.---.---. 11/01/2006 WED 13:57 FAX 912 261 0397 INTREPID USA/DRU 1o!I021 QEoPARTMEN-:- OF HEAL I H AND HUMAN SERVICES-"'-'- RS FOR MEDICARE & MEDICAID SERVICES , ST..Q.i!:MENT OF D-E;:JCIENCISS : A.;':~ ;':.,AUOF ::::J!1~:r:TIG~...' . (Y.,) PP"OVlDEPJSI)PPUE.'9.'CUR ::;n:'!"'!f~~O~': :-:~~~[:: 1 ''"~ ..:.~~ NAME OF PROVlOeF: OR SUPPLrEM INTREPID USA HEAlTHCARE SERVICES (X,) 10 I PREFIX TAG j I G 1591 COntinued From page 6 G 159 484. 18(a) PLAN OF CARE SUMMARY STATEMeNT OF DEFICIENCIES lEACH DEFICIENCY MUST BE PReCEEOEIlBY PULL REGUlA TO~Y OP.lSC IDENTIFYING INFORMA.TION} The plan of care developed in consultation with the agency staff covers ail pertinent diagnoses, including mental status, types of services and equipment required, frequency ChisilS, prognosis, rehabYitalion potential, funetional limitations, activities permitted, nutritional requirements, medications and treetrnenlS, eny safely measures to' protect against injury, instructions for timely diSCharge or referral, and any other appropriate items. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to obtain wound care orders snd blood sugar paremetars to trigger physiclar notiffeation for 2 of 19 sampled patients (#12 and 19). FindIngs were: 1. The clinical record for patient 11 12 revealed dressing changes by skilled nurse on 07/28, 31 and 08104, 09 to the right knee. There were no physician orders for dressing change to this area. An Interview with the administrator on 08114106 at 4:00 p.m. confirmed that there was not an order on the plan of eare for dressing changes to the abOve area. 2. The piGll of Care daled om 1/06 to 09128/06 i for patient #19 with primary diagnosis of diabetes I mellitus lacked parameters lor blood sugar (BS) I monttoring. I An intervie'", with the administrator on 08/1 i 106 at I 0900 a.m. ';onnrmed the plan of care lacked I , , FORM CMS-25S7(02-9g) Previous V"lliioos Ob!:oIe:te :-JC:"lt ~c: .;~::....:, -.-,..------ C!C)lIrJTcn. nRnn"'nn.::: FORM APPROVEQ OMB NO. 0938-0391 t>'.2\ MUl T(~ '::O!-J~LPC'!1o.11.! . .~~~ OATESU~IEY i" !I!~ !I~ !:>1"'/7 :C~';:'LC:7C;:; !'? '\"'.H~:;... , ~Su ~; JZC~e .....----~--_.... I mEET ADDRess. CITY, STATI'.lIP CODE ~S28 DARlEN HIGHWAY, SUITE 201 I BRUNSWlCK, GA 31520 I 10 I PROVIOER'S PlAN OF CORIlECTlON . PRefIX (CACH COAREc:1lVE ACTION SHOUlD BE I TAG CROSS-P.E~EP.ENCEb TO THE APPRO?RIA Ti: I . OEFICIENC\') I G 159i . . G 159/ The administrator will assure that the ; . plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment . required, frequency of visits, prognosis rehabilitation potential, functional limitations, activities permitted, . nutritional requirements, medications and treattnents, any safety measurcs to protect against injury, instructions for timely discharge or referral and any other appropriate items by in-servicing all skilled staff on "Writing an Effective eMS 485". The Director of. Professional Services andlor designee will monitor ongoing compliance by reviewing all Plans of Care to include J change orders for a period of 2 months then the administrator'will re-evaluate for the need of coutinued 100% review Ifcompliance with plan 0[= I policy is less thaJJ 90% during this 2 month period 100% review will ; continue for another 60 days and all ! clinical staff will be re-educated on following the plan of care and I documenting the same. Ongoing I compliance will then be monitored by sampling at least 20% of all CMS I 485'$ submitted each week. ! I I lXO) I """"LEnON I DATE I I 9/18/06 . racfUtrK): G.c.'17073A Ii continUiition sheet Page 7 of 12 11/01/2006 WED 13:58 FAI 912 261 0397 - uU""(T;~Eitf-t:li<-H~S~IGE5 CENTERS FOR MEDICARE & MEDICAID 5 RVlCES STATEMSHT OF OEl'ICIENO,ES IX1I PROVIOERISUPPlIERICLL< i A,"iD Pi..Al\EJf C(JFi!?Er:tIOI\i :' - :i)FtJ..o""7JC';C,c,,,.:w "'to;~f~' j j INTREPID USA/BRU 1l!J022 _.._....--PPINTC'tl- I'1Rnn"nn~ FORM APPROVED OMS NO. 0938 391 1)(2) Mut TIPl! r.Of'l!15~~T!l}~ / iA fRU!01NG ., --------.'" --'-" ,~3:~ O..o.'!'E SVR'JEY j ........J1r."!~\:: j ........ -'... , :';';'0.'''-'''''''''' , NAME. Or PROVIDER OR SUP'PUER STPaT ADDRESS. CITY. STATO. ZIp CODE INiRe:pro USA HEAL THCARE SERWCcS 3528 ONlIEN HIGHWAY, SUITE 2Q1 BR.UNSWlCK. GA S1S20 (><Al/O I SU""""-RY STATEMENT OF DeFICIeNCIES I 10 I FROVIDeR'S FlAIl OF CORRECTION , I I C""~nON PREFiX I (EA~H DEFICIENCY MUST BE PRECEEOI!il BY fULL I PREF", (EACM CORRECTlVE ACTION SHOULC BE TAG REr.uLATORYOR LSC IDENTIFYING INFORNATION) TAG r ~ERENCEO TO TliE APPROPRIATE OAi~ OErlClENCY) I G 159 C~!1tJnt:ed F 10m ;:iig& 7 i G 159/ . I eViden~-e of as parameters. G 164 i The administrator will assure that G 164 484.18(b) PERIODIC REVlEWOF PlAN OF 9/18/06 CARE agency professional staff promptly Agency professional staff promptly alert the alert the physician to any changes that phy~icilln to any changes that suggest a need tc suggest a need to alter the plan of care aller the plan of care. by in-services all clinical staff on noting changes in patient condition, This STANDARD .Is not met as evidenced by: . who to report to, when to report to physician and documentation of Based On clinical realrd ,..view and staff notification. The Director of interview, the agency failed to notify the physician Professional Services andlor designee of a patient 131/ and a new wound for 2 of 19 will monitor compliance by sampled pafients (#2 and 12). F"lIldings were: reviewing all commUDication notes 1. The physical therapist CPT) note dated and any documentation of notification 08114/06 for patient #2 reflectedthatlhe patienfs to physician for a period of 2 months caregiver staled tile patient ended up on the floor then the administrator will re-evaluate while trying to pull up clothing. The PT note for the need of continued 100"10 reviev\ indicated "no significant injury, some bruising of Ifreviewed results are 90% or greater the elbows trying to crnwIlO the chair." The record lacKed evidence the physician was notified CIOmpliance, ongoing compliance will of the incident be monitored by sampling at least 20% During an intarview on 08116/06 at 5:00 p.m. with of all clinical notes submitted yteckIy the administrator and director of operations, the to determine changes in patient's administra:Or confirmed the physician was not I I condition that.might warrant a change I notified of the patient's fail. The administrator in the plan of care. . I I also confirmed thal.it was the agency's I expectation that the physician be notified of all I I patient falls. ! I I I 2. DUring record review ior patient #12 the SN I , ; I I i -- ..-....... -"",,,. I I notiiying the physiCian of wound located on right I I knee. I ,. I I . , ;,!':':~ i~ 'M'':;:: ...,: ...... :...."';!'!~ ~ORM CMS-256i(02-99) Pre-noli:; Vet$ians Ob$otefe ell!!nt!D: 41....11 Faewrty ,!:t. GA1':7C:'~ tf contil'luoriGn sht!t Pace ! of 12 .- -- --.---.--.---..-- ------.. -- __no .__.____._ 11/01/2006 WED 13:58 FAX 912 261 0397 INTREPlD USA/BRU . -(;lEP;<>;R'"~Il~trmilUFI01i1II\I'(:;I:HVIl;E:' CENTERS FOR MEDICARE & MEDICAID SEFMc S I $TA"1EMENT OF DEFICIENCII!S fXn !'ROVf~RlSUP~UEPJCI.l~ ! A""D Pl.AI" r::'~ 'X'=.:is:,:.IO!'-! I' '~=.~.~F:':~.n?N N~M==~' I ..i """':44 NAME OF PROVIOtP. OA SUPPLIER I/liTREi'ID USA HEAl ,HeARE SERVICES (>00)10 1 ~REF1X TAG SUIIMARY STATEMENT OF DEFICIENCIES (E'OH DEFIClEHOY MUST BE PREcEEOEO BY FUU REGULATORY OR lSC 'oamI'YING INFoRMAnoN) G 1S4 j COiitirrued From page 8 An interview With the administrator on 08/14/06 at 2:00 p.m. confirmed the SN failure to notiiy the physician of wound on right knee. G 215 464.3€(b)(2)(ilQ COMPETENCY EVALUATION & IN-SERVlCE lRAI The home health aide must receive at least 12 hours of in-service training during each 12 monJh period. The in-service training maY be furnished while the aide is furnishing care to the patient This ST A/'IDARD is not met as evidenced by: Based on review of personnel files and staff interview, the agency failed to demonstrate that .home health aides completed 12 hours 01 in-service training within a 12-month period for 2 012 aides (employees #4 and 5) who required in-service training. Findings were: An interview on 08/14106 at approximately 2: 15 p.m. wIth the administrator indicated that the home health aide in-service training was conducted annually, January through December. During an interview 9n 06/15/06 at 1:30 p.m., the I administrator was unable to confirm that employee #4, a home health aide with a hire dale I oi 05124/04, had completed 12 hours oi in-service I training forthe year 2005, and that employee #5,/' a home health aide with a hire date of 01/02180; completed 12 hours of in-service training for the years 2004 and 2005. nie administrator revealed, that the in-service training book for the heme I I health aides for the years 2004 and 2005 had I been misplaced. . G 23Sjd84.46 CL!NICAL RecORDS I I I FORM CMs-..uG7(02-g9} FlPIieus VQf$ion!il ObRJIste Eve!ltlD: 414t.11 -----.-"'-- ---- I(!JUZ~ p~l"':e~.~~ FORM APPROVED OMS NO. 0938~391 rY..Z.~ M!.JL TJPLE CON$'rRur...:ncitot i A 3:..I~. ~I!,IS ,C{3} uJi.iE SLJRVE"f I C:.JMP._Ei;~ ~ '_'..;I~~ _.--------~ I STREET ADDRESS. CITY, STAr., ZIp CODE i 3S2B DAI!IEN HIGHWAY, SUITE 2~1 BRUNSWICK, GA 31520 I 10 PROVIOER"S PLAN OF COf{RECTION PREfIX (EACH CORRECTIVE ACTION SHOULD BE TAG OROSS.REF:!I!NCED TO THEAPPROPRIATE OEFICII!NCY) I I CO 1641 I G 2151 The adminislntor will.assure that all . home health auies receive at least 12 hours of in-service training during each period by developing a binder to contain a list of in-services to be presented to aides for the year of2006. The book will also contain the current in-services with date and hours of presentation to each aide and a sign in sheet for acknowledgment of receipt of in-service. In-services binder will be kept in the administrator's office, The I Director of Professional Services or designee will monitor ongoing compliance by reviewing the binder at least Quarterly to ensure education is on track for 12 hours training during the year. I I I ! i I G 236/ I ! Faciiil'J iO.: GA117073A iiGi ~ i f20ijO i i (lIS} i COMPli110N .i ~TC I I I 9/1 8/06 I I I tf continuaticn Shesf Page 9 of 12 11/01/%006 WED 13:56 FAX 91% %61 0397 INTREPID USA/BRU -"""1JEP"AATMFJ<JT'OF""11E):ITFfANtrRUI\1;A.1ifSE'RVIT:t:S------.._._ . CENTERS FOR MEDICARE & MEDICAID SERVICES - sn TENEilJ7" OF D~FIC'=NCIES i .1I.,,!~ !=t!...t'~"! ~~l; ':."DR~~C'!'!"~: I ~!l ~'JIo=.c...SUPPUERlClV' 1 !==N"!':n:....;:c;'-~ ~~t...M::::::;::. NAME OF PROVIDER OR SUPPUER L -''!':~4 iNTRePiD USA HEAL THCAAc SERVICeS (X4) JO ! PREFIX I TAG SUMMARY STATEMENT OF OEFIClENClES (c..cH DEFICIENCY MUST SE PRECEEDEO BY FULL REGULATORY OR L.SC IDENTIFYING INFORMATIoN) . G 235 Contir,ued From page 9 A clin&;al reCOrd containing pertinent past and current findings in aCCordance with accepted professional standards is maintained for eve/)' patient receiving home heallh services_ In addition to the plan of care, the record conmins appropriate identifying information; name of phy-$iclan; drug, dietary, treatment, and activity orders; signed and dated clinical and progress notes; ~.op;es of summary reports sent 10 the attending !lhysician; and a discharge summary_ This 5T ANDARD is not met as evidenced by: Basecl on clinical record review and staff interview, /he clinical record tailed to contain documentation of physician notification, blood sugar Values, Wound healing and a 6O-day summary for 5 of 19 sampled patients (#7, 8, 10. 11, and 16)_ Findings were: 1. The plan of care dated 07/07/06 for patient tI7 required the skilled nurse (SN) to. weigh the patient every 5N visit and to report a weight variation of 2 to 3 pounds_ The inllal weight recorded on the inita! comprehensive ilSSe5Sll1ent dated fJ7107106 was 110. The SN nole deted 07/31/06 indicated a weight of 112 and the SN note dated 08104/06 indicated a weight of 114_ At the time of the- survey the notes lacked evidence that the physician was notffied of the weight variation. , I' An interview pn 08/15/06 ilt 4:30 p.m_ was conduc1ed with the administrator and director of I' operations tp determine if the phYSician was I aware of the weight gain. At that time, the I administrator confirmed that the physician was I FORM CMS-25rn02-9Q) l'l"9vious Versior1& Obsolete E".,cePlt 10; 41411 \ '-..-.----. -.. ..--. .--'---"-'---' , I 10 I FREFIX I TAG Ij!J024 .~R:~l,!,[~: aeP~~Ca.- FORM APPROVED 0MB NO. 0938-0391 . pQ) IIotU!. TIPLE CONSTP.UC"rJOt>l , - . jp~ ~.!.Ht.""!!J . {X'2} DA TE SU~~ 1 .cOjyjP~::iE~ J~ ".-J:NG 5i"rI:1!e-r ADORESS. CITY. STAT!. Zip CODe 3528 DARIEN HIGHWAY, sUITE Z01 BRUNSWICK, GA 31$20 PROVlDEIl'S PlAN OF COIlRECTlON (EACH CQRRECTlVE ACTION SHOUlD IE CROSS-RS'EReNCED TO _ APPROPRIATE DEFIClE'NCY) G 236 The administrator will assure that a clinical record containing pertinent past and current findings in aocordanet with accepted professional standards is maintained for every patient receiving home health ser:vices by in-servicing all agency staff on appropriate and required. docwnentation for the clinical record.. The Director of Professional. S eMces or designee will monitor ongoing compliance by performing 100% clinical record review on all patient records for-2 months then the administrator will re-evaluate for the need of contiriued 100% review. If compliance with plan of care policy is less than 90% during this 2 month period, 100% review will _ continue for another- 60 clays and all clinical staff will be re-educated on following the plan of care and docwncnting same. Ongoing compliance will be monitored by sampling at least 20% of all clinical notes submitted each week. I I I I ,/ FaciSfl lO: GAt 17073A OSiy; 102(,;05 I (X5) I COMPI.eilON "T! 9/18/06 I I I i i I lfcontinuotion ::Ihe~t P!g~ 10 of 12 -'-~-'-'---"-' FOT 912 261 0397 11/01/2006 WED 13:59 ~ DQII\IT-=r)_ AAI':tn'~fl" -- -"DEPARTliilENTOFFlEAUR ANlJRO!iWIrSERvTCES-.-'--- - -.--..-..-.:- -.--.---- ---- -. .----.FORM APPROVEI CENTERS FOR M DICARE & MEDICAID SERVICES OMS NO. 093B-039 f S'!'"ATEMENT C-F" OEFlcr~NCI~.5 1.-:':1:: "'!..P,I-: ~~ ~~~E~~Ja~~ (X1} ~P.OVIDER'SuPPUeJYCUA ! :~;!'~;!~!~'l.:!C.~.1 N:....':'.mEP I" . NAME OF PRO"lOE,- OR SUPPLIER --,/'.i.I'. INTREPID iJSA Hl:AL THeARE SERVICES (X411D .Ii $UMMAAY STATEMENT OF OEFICIENCIES PREFIX (EAC" O€FIC'ENCY MUST PE PREDEEDEO sr FULL TAG REGlJLo.TORY OR LSC 10ENTIFYiNG INFDRMA TlON) G 2361 Continued From page 10 not notified of the weight gain. An interview On 081,7106 at 10:50 a.m. with the administT2tor and director of operations revealed that the SN Communicated the weight gain to the physician: however, the SN failed to document the .- I communication in the clinical record. 2. A physician's order dated 06/22/06 for patient I #8 required the SN to visit 2 times a week for 1 . week, then 1 time a week for 1 wee~ for wound I care 10 the right (R) Upper arm. The SN note dated 06130/06 racked evidem;e wound care was provided to the (R) upper <Inn. An lilterview On 08116/06 at 5:00 p.m. with the administrator and director at operations revealed that the (R) upper arm WOUnd held heared; however, the aaministrator confirmed that the SN faile1;1 to document that III 'II Wound had h!!aled. 13. Review o'-the clinicar record for petien! #11 lacked evidence of a 60-day summaI)' r;rf care for the time period 04/14/06 to 06/12106. r During an interview on 08116/06 at 3:30 p.m. with I the administrator and director of operations, the administrator continmed that the 6O-day summaty of care fer the time period 04/14/06 to 06/12/06 I had not been done. Late entry docymentalion of the 60-day sumrnal)' dated 08/17106 was r Provided io the surveyor on 06/17106. A fax i confirmation was aiso Provided wl1ich indicated I' the 60 day summary was sent to the phYSician on , (06/17/06 all0:1 0 a.m. i 4. The plan of care dated 07/18/06 for petient , 1#16 required Ihe SN to notify the physician of a I blood sugar value greater than. 350 and under 60'1 The SN notes dated 1, 3, and B August200S r FO"M CMs-2567"(02-9SJ f=raYQS VSl'$icn:: Ob:;:oIelg Ev.::ntlO: .''1L1i ----- U__ __._ _"'_n._.._..__ INTREPID USA/BRU I(IJUZ~ J r)"..2~ MUl rrPLE t.ONSTP.UC'!1af.l 14_ 91}1!....!Y'!-JG f'):2~ DATE SlJP-V!" . . c6f.f"..~~ !?. :'~.~NG , '-~-----~-'-'" :;SI'~j'.:~C~ STREET ADOP.ESS. CITY. STATE. ZJF coo. J$28 DARIEN HIGHWAY, SUITE 201 8RUNSWICK, GA- 31$20 I jQ I PROVIDER'S PlAN OF CORP.ECTION PREFIX I 1!iACH CORRecTIVE ACTION SHOULD aE . TAG I CROSS-~RENCED TO me APPP.OPR'ATe I DEFICIENCY) , I 00;) COMPLETION DA", , , ! I G 2361 I I I I { I , I I I i I I , ; , I , If cCitt!nu2001'1 sheet ;:'age 11 ot 12 F~IO: GA1170731.. -- - -'-"-- -- -------.-.-- -.--- ---.--.---- 11/01/Z008 WED 13:5~ FAX 91Z Z81 0397 - [l~PARTIii1ENTOFHEAIJHfl:NDHONi7\1'TSERVICES---- .__. _____ _____ .__ __ ___ CENTERS FOR MEDICARE & M DICAID SERVICES STATEMENT OF ~::FICI5NC'ES i ,A:-:C r"L!"ri....(!F -:::~~=!ECr:OI.: . O(!} PP.OVIOE~UP!'L1E;~'Il. :De:~r:f!:lc.~."!!Cr.' .~:J~J.Eer.- of ~ "!".,.~.:..( NAME OF PROVIDER OR SUPPLIer. INTREPID USA HEA1 THCARE SERvlCES (X,) JO ! PReFIX j TAG I I SUMMARY STATEMENT OF OEFlCIENCIE5 (EACH OEFICIENCY MUS. Be PRecEEOED BY FULL REGUlATOFtY OR LSC IOENlJFYJNG INF"ORMATrON) ! , G 2351 Ca;;ti~ued From page i 1 I I indicated the blood sugar was grealer than 200; : howev~r, the SN failed document the blood sugar I value, . An interview on 06117/06 at 10:40 a.m. with the administrator and director of operations confirmed that l!1e SN failed to document the blood sugar value. 5. The "Ian of care dated 06104106 to 06102106 for patient #10 required lhe$N to assess blood sugar levels on each SN visit aller next SN visJt , beginning 06/15/06 report as findings to the physiciall Although, as logs were maintained in the home lhe~ were no documenlation in the SN noles that the SN assessed or reported findings to the physician, . An interview with the administrator on 08117/2006 at 09:00 am. confirmed that the SN failed to document or report SS levels to the physician. I I I I I I I I I F'ORM CMS-;Q67[02-t19J Pr9viau:= Vemion~ ObsoIeco EvenlIO: ~~..~~\ ... -'-'-.-..-.---.--- ----- INTREPID USA/BRU 1CI0Z8 .----e.~Eo;""D.a.'30t2.QQ5.._ ,,"ORM APPROVED OMS NO. 0 38"()391 {Y.2} MUL TIPj e CONST?!JCTlON r ;4, fJUltOI""G , fr :..~,'!\iS -.- - '---..--. -- SiR&. ADDRess, CITY. STATE, ~, CODE 3521 DARIEN HIGHWAY, SUITE 201 BRUNSWICK, GA 31520 /0' PROVIDER'S PlM' OF CORRE"CTTON PRe;FIX I' (OACH CORRe;CTlVl! AC"ON Sl10UI.O BE I TAG CROSS-REFERENce;O TO T>lEAFPROPR'A Te I OEFICIe;NCYj I I I i I I I , 02M! I I I i I i I I Facill{'; 10: G.!:'i11072A :;OM(",__c:i~ ~... ...-,~~...- ;,;:'1 :l.........;.:t. , I (Xl, I COMPLETION , DA.T! I , I i I I I I I , r i I I , I If continu3IUon shaet Page 12 Of 1(: ..-----.--- --- -- --..----.-.--.-. :i'- APPENDIX C BOD/Officers ( Intrepid USA HeaIthcare Services Board of Directors Peter Harris 528-98-4721 DOB 7/2/63 Bill Roberts 458-06-5461 DOB 3/14/56 William H. Edwards 257-94-9625 DOB 10/24/54 Address for above persons is : 6600 France Avenue South Suite 510 Edina, MN 55435 952-285-7300 William H. Edwards, Jr. 59 Honour Avenue, NW Atlanta. GA 30305 Hnme 404.467.1703 Cell 770.630.8919 E-mail: bcdwards@guardianhomecare.us CURRICULUM VITAE EDUCATION Graduate KENNEDY-WESTERN UNIVERSITY, Cheyenne, WY Master of Science in Business Administration, 2000 Thesis: Managing Succes!iful Acquisitions and Mergers Through Efficient Due Diligence and Transitional Activities UNIVERSITY OF GEORGIA, Athens, GA Gradllate study in Public Administration, 1980-1981 Undergraduate UNIVERSITY OF GEORGIA, Athens, GA Bachelor of Science in Education, 1980 MEDICAL CENTER OF CENTRAL GEORGIA SCHOOL OF NURSING, Macon, GA Nursing Diploma, 1975 LICENSURE Registered Professional Nurse - Georgia and Tennessee Licensed Nursing Home Administrator - Georgia (inactive) EMPLOYMENT GUARDIAN MANAGEMENT GROUP, L.L.c., Hixson, TN, 2005-Present ChiefOoeratinf! Officer. Responsible for directing operational and clinical initiatives and new business development for all Guardian Homecare and Hospice locations. Implements clinical specialty programs to appropriately maximize profitability and enhance clinical quality outcomes. Directs sales and marketing professionals and strategically implements strategies for growth and expansion. Develops and monitors operational mctrics to optimize financial performance. Current platform: 12 locations in GA and TN; revenues in excess of$25mm (95% Medicare). HOUSECALL MEDICAL RESOURCES, INC., Nashville, TN, 2003-2005 Vicr! President and ChierClinical Officer. Responsible for leading the overall clinical initiative for this $100+mm (SO% Medicare) home care organization overseeing all clinical operations for home care and hospice. Participates as an integral member of the senior management team; implements quality improvement programs through the OBQI/OBQM process, JCAHO accreditation and regulatory compliance. Develops clinical specialty/disease state management programs with associated clinical pathways, outcomes data, care plans and policies/procedures for implementation. Charged with driving operational perfonnance through an enhanced clinical delivery system and ensuring clinical processes for optimal financial results across all product lines. TON OF TENNESSEE, INC., Memphis, TN, 2002-2003 Dillisional Vice President. Responsible for effectively leading, managing, and directing all personnel and business activities within the assigned division, including all business lines (Medicare-certified, Medicaid, commercial insurance, hospice, infusion, private pay, staffing, pediatric and high-tech services). Consistently deploy new or ensure adherence to established policies, procedures, guidelines, regulations and company norms developed in conjunction with corporate staff. Responsible for strategic and tactical operations as well as achieving financial goals of all business units. Company profile: Operated in fourteen states, $96mm annual revenue (85% Medicare), 3100 employees. HAROLD GLEN, L.L,C., Memphis, TN, 2000-2002 Princinal and Founder. Chartered to engineer and market a comprehensive home health data management information system designed to analyze cost, utilization and case-mix data, clinical outcomes and disease management protocols and monitor quality indicators for continuous improvement processes. Developed as a point-of-care system to incorporate all payer sources and to interface clinical systems with all administrative and operational departments/divisions, i.e., intake. scheduling, billing, payroll, compliance. statistical/management reporting, etc. MEDSHARES, INC., Memphis, TN, 1994-1999 President and Chief Overatine omcer. Responsible for providing executive oversight, leadership and strategic direction to all subsidiary home health companies of Medsharcs, Inc. (Medicare-certified. owned and managed agencies, private services, infusion, HME and hospice) facilitating growth and expansion of programs and services. Monitored the financial pcrlormance of the organization working closely with the Company's Chief Financial Officer to achieve the Company's financial forecasts and earnings targets. Developed policy and articulated plans for both short and long-range company! departmental goals and objectives. Effected strategy through effective delegation of operational responsibilities through the Company's various operational matrixes. Appointed and evaluated the performance of divisional, senior and executive administrative officers as well as Presidents of operating business lines. Acted on behalf of the Chainnan and Chief Executive Officer in his absence or temporary disability. Chaired the Company's Compliance Committee and served on the Budget Committee and on the Board of Directors. Responsibilities spanned 300 offices in 26 states, employing 5500 individuals with 1998 revenues in excess of$380mm (90% Medicare). ABC HOME HEALTH SERVICES AND HOSPICE, INC" Brunswick, GA, 1985-1994 Senior Executive Vice President and ChierClinical Services Officer. Responsible for developing, implementing and evaluating a comprehensive home health medical services delivery system via existing networks while expanding through mergers, acquisitions and enhancements. Also responsible for managing field operations and assuring compliance with governmental regulations and corporate policies while administering and maintaining optimum standards of patient care. Company profile for 1994: largest privately-held, certified home health corporation in the United States; gross revenues in excess of $400mm (95% Medicare) with 6.5mm visits rendered; located in 23 states with over 400 locations. SEVP and CMSO directed 25 Senior and Regional Vice Presidents, five department managers and was responsible for over 10,000 field employees in both the certified, hospice and private duty arenas. BARRETT CONVALESCENT HOME, INC" Commerce, GA, 1987-1990 GRANDVIEW CONVALESCENT CENTER, Athens, GA, 1985-1988 IMPERIAL HEALTH CARE CENTER, INC" Atlanta, GA, 1983-1984 Nursinl:!/Administrarive Consultant. Surveyed facilities for compliance with federal and state regulations as well as adherence to established policies and procedures pertaining to total patient care. Reported deficiencies to facility Administrator with specific recommendations and assisted with implementing a plan of correction. GRANDVIEW CARE CENTER, INC., Athens, GA, 1980-1984 Assistant Administrator/Director of Nursinf! Services and In-Service Education. Assumed the responsibility for directing, supervising and budgeting various disciplines and departments within this 100-bed skilled nursing facility including total patient care. in- service education and orientation programs. quality assurance and utilization review, risk management, social services, activities therapy and medical records. Assured compliance with rcderal and state regulations for long-tcml care facilities. Served on the Advisory Committee to the Medical College of Georgia School of Nursing, Augusta and on the Planning Committee for the Certificate Program for Hospital Statf Development Personnel, University of Georgia, Athens. SAINT MARY'S HOSPITAL, Athens, GA, 1978-]980 Utilization Reviev.' Coordinator. MEDICAL CENTER OF CENTRAL GEORGIA, Macon, GA, 1975-1978 Senior Stair Nurse, PROGRAMS/WORKSHOPS PRESENTED "Managing Multi-Site Agencies" Michigan Home Health Association's 1994 Winter Conference, Lansing, MI "Decentralizing Nursing Practice Systems: Strategies for Managing Multi-Site Operations" The Eighth National Nursing Symposium on Home Health Carc. The University of Michigan School of Nursing, Ann Arbor, MI, ]993. "Utilizing Pay-Per-Visit in the Home Care Arena: Providing a Competitive Compensation Program While Rewarding Productivity" The Seventh National Nursing Symposium on Home Health Carc, The University of Michigan School of Nursing. Ann Arbor, MI. 1991. "A Guide for Productive Staff Growth During Acquisition, Transition and Merger" (CEU approved) National Association for Homc Care Annual Meeting and Home Care Exhibition, Dallas, TX, ] 990. "Acquisition, Transition and Merger: A Guide for Productive Growth" (CEU approved) The Sixth National Nursing Symposium on Home Health Care, Thc University of Michigan School of Nursing, Ann Arbor, MI, ]990. PROFESSIONAL MEMBERSHIPS Tennessee Association for Home Care Memher. 1994-Prcscnt National Association for Homc Care Memba, ) 985-Present American College of Health care Executives Associate. 1992-] 997 American Organization of Nurse Executives Member. 1992-] 997 American Management Association Member. ] 990-1996 National League for Nursing Member. 1994-1995 GREG YON ARX 11313 Louisiana Avenue South Bloomington, MN, 55438 H: 952-995-0655 C: 612-839-1859 GENERAL SUMMARY Chief Financial Officer with comprehensive knowledge of the financial and operational aspects of health care provider organizations and closely held corporations. Known as a high integrity professional with strong analytical, strategic planning, and acquisition skills. Proven ability to implement financial systems, incorporating the intricacies of a highly regulated husiness while successfully increasing productivity and growth. Valued for leadership and problem solving skills as well as maintaining effective relationships with banking institutions, reimbursement agencies, auditors and consultants. Excellent communication and interpersonal skills have supported successful eollahoration, negotiation, and positive partnerships with staff, outside vendors and organizations. Have consistently achieved professional and company objectives by combining visionary, strategic, and tactical tinancial expertise, which produce bottom-line results and financial strength. SYNOPSIS . Financial Planning Budgeting & Forecasting Strategic Planning . Acquisitions . Margin Improvement . Increased Growth _ Financial & Operational Expertise Relationship Building & Management Successful System Implementation . . . . EXPERIENCE CHIEF FINANCIAL OFFICER Intrepid U.S.A, Inc. Edina, MN May 1998 to Present . Successfully directed consolidation of twelve substantial acquisitions, which increased revenues from an annualized rate of $11 ,000,000 to over $200,000.000. . Consistently created value by increasing EBITDA, managing cost and achieving desired levels of growth. . Strategically negotiated financing with multiple banks to maintain financial integrity and support aggressive expansion. . Reorganized financial systems to increase efficiency and control while enabling continued growth. . Efficiently directed the conversion from multiple generallcdgcr and account payable systems to a standard general ledger and account payable system: Solomon IV. . Provided oversight of the conversion of six billing and payroll systems to one standardized system. . Implemented use of individual office budgets enabling each office to receive comparative information of budget vs. actual. . Effectively negotiated rates for all work-compo insurance and benefit plans for the company. CHIEF FINANCIAL OFFICER, CO-OWNER Tealwood Care Centers, Minneapolis. MN Jan 1989 - Dee 1997 . Integral in the startup and growth of the company increasing from five to seventeen facilities. . Developed reporting systems to comply with third party reimbursement, operational reporting, bank reporting, and tax regulations. Page I 00 GREG VON ARX 11313 Louisiana Avenue South Bloomington, MN, 55438 H: 952-995-0655 C: 612-839-1859 . Completed all Medicare cost reports and Medicaid cost reports in seven states and coordinated the year-end financial review and tax returns. . Implemented effective programs to put ancillary programs in place and certify all facilities in Medicarc. . Responsible for preparing or reviewing all acquisition pro formas and financial statement preparation. . Successfully managed the cash flow of the organization, which included setting up various sweep accounts. . Effectively converted all financial aspects of new acquisitions to Tcalwood systems and trained all new administrators and bookkeepers on Tealwood systems CONTROLLER HMU Management Corporation, Edina MN March 1987 - Dec 1988 . Designed and implemented all financial aspects needed for setting up a nursing home Management Company. . Developed centralized general ledger accounting for 1987, which created substantial savings in outside accounting fees. . Centralized all payroll providing better reporting and control. . Centralized accounts payable providing improved cash management. . Responsiblc for filing of all Medicaid cost rcports in seven states. DIVISION ACCOUNTING COORDINATOR Beverly Enterprises, Plymonth MN April 1985 - Feb 1987 . Supervised staff of 12 regional accountants that provided accounting and bookkeeping systems support to over 140 nursing homes. . Reported directly to President of Northern Division & provided operational analysis for the Northern Division Management Committee. . Supervised credit and collections manager. . Developed & presented reimbursement maximization seminars for Minnesota, Wisconsin and South Dakota. . Developed management tool for monitoring reimbursement. . Assisted in budgeting Medicaid revenue for six states. Internal Auditor . Performed operational audits on nursing homes in eight different states. . Participated in only internal audit of a division office. . Was instrumental in the standardization of the internal audit guidelines and work papers for the company. Education Uniform Certified Public Accountant Exam, 11185 . Successfully completed all four parts ofthe exam in first sitting. University of Wisconsin - Eau Claire, 08/80 - 05/84 . Bachelor of Business Administration with a comprehensive accounting major. Page 2 of3 GREG YON ARX 11313 Louisiana Avenue South Bloomington, MN, 55438 H: 952-995-0655 C: 612-839-1859 Pagd of3 APPENDIX C Articles of Incorporation ( AMENDED AND REST A TED ARTICLES OF INCORPORATION OF F.e. OF GEORGIA, INe. I, the undersigned, as President of F.C. OF GEORGIA, INC. (the "Corporation"), do hereby certity that the sole shareholder of the Corporation by action by written consent dated January 30, 2006, has resolved to amend and restate the Articles of Incorporation in their entirety, to supersede the original Articles and all amendments thereto, as follows: ARTICLE I Name The name of this corporation is F.C. OF GEORGIA, INC. (the "Corporation"), ARTICLE II Registered Office The address of this corporation's registered office in this state is 6600 France Avenue South, Suite 510, Edina, Minnesota 55435. ARTICLE III Authorized Capital The total authorized number of shares of this corporation is 100,000 shares. The Corporation shall have authority to issue 100,000 shares of Common Stock. All stock shall have the par value of one cent ($.01) per share. ARTICLE IV Cumulative Voting Prohibition Shareholders shall have no rights of cumulative voting. ARTICLE V Non-Voting Equity Shares The Corporation shall not have authority to issue any non-voting equity securities. ARTICLE VI Preemptive Rights Prohibition Shareholders shall have no rights, preemptive or otherwise, under Minnesota statutes Section 302A.413 (or similar provisions of future law) to acquire any part of any unissued shares or other securities of this corporation or any rights to purchase shares or other securities of this corporation before the corporation may offer them to other persons. ! 180999.2 ARTICLE VII Limitation of Director Liability A director of the corporation shall not be personally liable to the corporation or the shareholders of the corporation for monetary damages for breach of fiduciary duty as a director, except for (i) liability based on a breach of the duty of loyalty to the corporation or the shareholders; (ii) liability for acts or omissions not in good faith or that involve intentional misconduct or a knowing violation of law; (iii) liability based on the payment of an improper dividend or an improper repurchase of the corporation's stock under Minnesota Statutes Section 302A.559 or on the sale of unregistered securities or securities fraud under Minnesota Statutes Section 80A.23; or (iv) liability for any transaction from which the director derived an improper personal benefit. If Minnesota Statutes Chapter 302A hereafter is amended to authorize the further elimination or limitation of the liability of directors, then the liability of a director of the corporation, in addition to the limitation on personal liability provided herein, shall be limited to the fullest extent permitted by Minnesota Statutes Chapter 302A, as amended. Any repeal or modification of this Article by the shareholders of the corporation shall be prospective only and shall not adversely affect any limitation on the personal liability of a director of the corporation existing at the time of such repeal or modification. ARTICLE VIII Directors Action by Written Consent Any action required or permitted to be taken at a meeting of the Board of Directors may be taken by written action signed, or consented to by authenticated electronic communication, by all of the directors then in office, unless the action is one which need not be approved by the shareholders, in which case such action shall be effective if signed by, or consented to by authenticated electronic communication, the number of directors that would be required to take the same action at a meeting at which all directors were present. ARTICLE IX Shareholders Action by Written Consent Any action required or permitted to be taken at a meeting of the shareholders may be taken by written action signed, or consented to by authenticated electronic communication, by shareholders having voting power equal to the voting power that would be required to take the same action at a meeting at which all shareholders entitled to vote were present. If an action is taken without shareholders' unanimous written consent, the corporation must notifY all shareholders within five days of the effective time of the action of the text and effective time of the action. ARTICLE X Dissenters' Rights Prohibition Pursuant to Minnesota Statutes Section 302A.471, subdivision I(a) (or similar provisions of future Jaw), a shareholder shall have no right to dissent from, and obtain payment for the fair 1180999.2 2 value of the shareholder's shares in the event of, an amendment of the articles that materially and adversely affects the rights or preferences of the shares of the shareholder in that it: (1) alters or abolishes a preferential right ofthe shares; (2) creates, alters, or abolishes a right in respect of the redemption of the shares, including a provision respecting a sinking fund for the redemption or repurchase of the shares; (3) alters or abolishes a preemptive right of the holder of the shares to acquire shares, securities other than shares, or rights to purchase shares or securities other than shares; or (4) excludes or limits the right of a shareholder to vote on a matter or to cumulate votes. I FURTHER CERTIFY that the foregoing Amended and Restated Articles of Incorporation have been adopted pursuant to Chapter 302A of the Minnesota Statutes. Further, such Amended and Restated Articles of Incorporation do not provide for the exchange, reclassification, division, combination or cancellation of nay issued shares of the Corporation. IN WITNESS WHEREOF, the undersigned has set his hand this y;+-- day of January, 2006. ~"L.. Preside Subscribed and sworn to before me on this ?>o\'---day of January, 2006. e. ANITA loA. SUTTON. NorARY ~ '8 Ily ~u UC. MiIIIN€SOTA CommIsoion E.oi*osJan. 31. 2010 NO~ I\'INE501/\ SI"WS~E~T OF STATE DEP""i=ILED \J~~ 6 1 100\'1 ~. ~""....,._~A.~rl " ( 180999.2 3 DC, De-~(~ 1111...1111I111 5523620012 ARTICLES OF INCORPORATION OF F.e. OF GEORGIA, INe. The Articles of mcorporation of F .C. of Georgia, mc., a corporation organized and existing under the Minnesota Business Corporation Act shall be as follows: ARTICLE I General Provisions 1.1. Name. The name of the corporation is F.C. of Georgia, mc. (the "Corporation"). /vz.--- 1.2. Business Purpose. The purpose of the Corporation is to engage in general business purposes pursuant to the provisions of the Minnesota Business Corporation Act (the "MBCA"). 1.3. Duration. The duration of the Corporation shall be perpetoal. ./ (. , 1.4. Registered Offiee. The registered office of the Corporation is located at 6600 France Avenue South, Suite 510, Edina, Minnesota 55435. / 1.5. Powers. The Corporation shall have all of the powers enumerated in the MBCA. m addition, the Corporation shall have and may exercise all other powers necessary or convenient to elfect any or all of the business purposes of the Corporation set forth herein. ARTICLE 11 Stock 2.1. Total Authorized. The Corporation shall have authority to issue an aggregate of 2,500,000 shares of stock. The classes of stock which the Corporation has authority to issue, and the number of shares in each class, is described below. J 2.2. Common Stock. The Corporation shall have authority to issue 1,000,000 shares of Common Stock. 2.2.1. Volin!! Ril!hts. The holders of Common Stock shall be entitled to one vote for each share of Common Stock held by them. 2.2.2. Cumulative Volin!!. The shares of Common Stock shall not be voted cumulatively. 2.3. Non-Voting Common Stock. The Corporation shall have authority to issue 1,000,000 shares ofNon- Voting Common Stock. 2.3.1. No Votin!! Ri!!hts. The holders of Non-Voting Common Stock shall not be entitled to any voting rights (except as otherwise required by the MBCA or other applicable law). 2.3.2. Other Ril!hts. Except for the previously described difference in voting rights, the Non-Voting Common Stock and the Common Stock shall have identical rights and privileges. 2.4. Preferred Stock. The board of directors of the Corporation shall have authority to issue 500,000 shares of preferred stock. Said stock may all be of one class Of series of preferred stock, or may be of more than one class or series of preferred stock. . 2.4.1. Ri!!hts and Preferences. A resolution or resolutions providing for the issue of such stock adopted by the board of directors of the Corporation shall state and express (i) the designation of such preferred stock; (ii) its voting powers, whether full or limited, cumulative or not, no voting rights, multiple votes, or otherwis~; (iii) its powers, preferences and rights; (iv) its qualifications, limitations or restrictions; and (v) any other rights, preferences and attributes permitted by the MBCA. 2.4.2. Statement of Desil!nations. A statement setting forth the name of the Corporation and the text of the resolution, and certifYing the adoption of the resolution and its date of adoption, shall be filed with the Secretary of State of the State of Minnesota. The resolution is effective only when this Statement of Designations is so filed (except as otherwise stated in subsection 2.4.4 below). 2.4.3. Issuance of Shares. The shares of stock authorized by this Section 2.4 shall not be issued until the applicable Statement of Designations has been filed (except as otherwise stated in subsection 2.4.4 below). 2.4.4. Excention. Notwithstanding anything in subsections 2.4.2 and 2.4.3 to the contrary, if the shareholders have received notice of the creation of shares pursuant to this Section 2.4, before the issuance of those shares, then (i) the applicable Statement of Designations may be filed any time within one year after the issuance of the shares, and (ii) the resolution is effective on the date of its adoption by the directors. 2.5. Miscellaneous. Unless otherwise specified herein, all of the shares of the Corporation sball have (i) a par value of one cent per share solely for the purpose of a statute or regulation imposing a tax or fee based upon the capitalization of a corporation, unless such statute or regulation allows for a lesser fee based upon no par value stock; and (ii) a par value fixed by the board for the purpose of a statute or regulation requiring the shares of the Corporation to have a par value. In all other cases, all of the 2 shares of the Corporation shall have no par value. If a par value is established for a class of shares, the Corporation may nevertheless issue those shares for a consideration whose fair value is less than the par value of those shares. ARTICLE m Shareholders 3.1. Preemptive Rights. The shareholders of the Corporation shall not have any preemptive rights (except as may be otherwise provided by resolution pursuant to Section 2.4 above). 3.2. Corporate Debts. The shareholders of the Corporation shall not be personally liable for the payment of the Corporation's debts. 3.3. By-Laws. The shareholders of the Corporation shall have the right to adopt, amend, or repeal by-laws of the Corporation. 3.3.1. Exclusive Ril!hts. After the adoption of the initial by-laws, only the shareholders may adopt, amend, or repeal a by-law (i) fixing a quorum for meetings of shareholders; (ii) prescribing procedures for removing directors or filling vacancies in the board; or (iii) fixing the classifications, qualifications, or terms of office of directors. 3.3.2. Controllinl! Effect The shareholders always have the power to override actions of the directors or incorporator in adopting, amending, or repealing by.laws. Any such action taken by the shareholders may not be changed except by the shareholders. 3.3.3. Shareholder Manal!ement The holders of the shares entitled to vote for directors of the Corporation may, by unanimous affirmative vote, take any action that the MBCA requires or permits the board to take. As to any such action taken by the shareholders (i) the directors have no duties, liabilities, or responsibilities as directors under the MBCA with respect to or arising from the action; (H) the shareholders collectively and individually have all of the duties, liabilities and responsibilities of directors under the MBCA with respect to aud arising from the action; (Hi) if the action relates to a matter required or permitted by the MBCA or by any other law to be approved or adopted by the board, either with or without approval or adoption by the shareholders, the action is deemed to have been approved or adopted by the board; and (iv) a requirement that an instrument filed with a governmental agency contain a statement that the action has been approved and adopted by the board is satisfied by a statement that the shareholders have taken the action hereunder. 3.4. Vote Required for Shareholder Aetions. The shareholders shall take action by the affirmative vote of the holders of a majority of the voting power of the shares present and entitled to vote, except where (i) 3 the MBCA or other applicable law requires a larger proportion or number, or (ii) class voting is permitted. 3.4.1. Volin!! bv Class. The holders of a class or series of the Corporation's stock shall be entitled to vote as a class to the extent (i) required by the MBCA; (ii) required by other applicable law; or (iii) the resolution described in Section 2.4 hereof for a class or series of Preferred Stock permits class voting. 3.4.2. Required Vote. Whenever class voting is permitted, an action by the shareholders shall in all cases require the affirmative vote of the holders of a majority of each class or series entitled to vote thereon (except where the resolution described in Section 2.4 hereof specifies that the vote by any class or series of Preferred Stock requires a greater than m,yority vote). 3.5. Consent of Shareholders in Lieu of Meeting. An action required or permitted to be taken at a meeting of the shareholders may be taken without a meeting, by written action, only if the written action is signed by all of the shareholders entitled to vote on that action. The written action is effective when it has been signed by all of those shareholders. unless a different effective time is provided in the written action. ARTICLE tv Directors ( 4.1. Board to Manage. The business and affairs of the Corporation shall be managed by or under the direction of its board of directors (except to the extent otherwise provided in Section 3.4 and Article 5 hereof). 4.2. Number. The number of directors shall be fixed by, or in the manner provided in. the by-laws of the Corporation. Any such by-law may be amended by either the shareholders or the directors, and that amended by-law may either increase or decrease the number of directors. 4.3. By-Laws. The board of directors may adopt, amend or repeal by-laws of the Corporation (except to the extent that subsections 3.3.1 and 3.3.2 above provide to the contrary). 4.4. Liability. A director shall have no personal liability to the Corporation or its shareholders for monetary damages for breach of fiduciary duty as a director; provided, however, that the preceding shall not eliminate or limit the liability of a director (i) for any breach of the director's duty of loyalty to the Corporation or its shareholders, (ii) for acts or omissions not in good faith or that involve intentional misconduct or a knowing violation of law, (iii) under Sections 80A.23 or 302A.559 of the Minnesota Statutes, or (iv) for any transaction from which the director derived an improper personal benefit. 4.4.1. MBCA Amendments. If the MBCA is hereafter amended to authorize the further elimination or limitation of the liability of directors, then in addition to the limitation on 4 personal liability provided herein, the liability of a director shall be limited to the fullest extent permitted by the amended MBCA. 4.4.2. ReDeal or Modification. Any repeal or modification of this Section 4.4 shall be prospective only, and shall not adversely affect any limitation on the personal liability of a director of the Corporation existing at the time of such repeal or modification. 4.5. Vote Required for Board Actions. The board shall take action by the affirmative vote of a majority of directors present at a duly held meeting (except where the MBCA or other applicable law requires the affirmative vote of a larger proportion or number). 4.6. Consent of Directors in Lieu of Meeting. An action required or permitted to be taken at a meeting of the directors may be taken without a meeting, by written action, if the written action is signed by the ntimher of d;rectors that would be required to take that action pursuant to Section 4.5 above. Any such written action is effective when it has been signed by the required number of directors (unless a different effective time is provided in the written action). ARTICLE V Shareholder Control Agreements 5.1. Authorized. A written agreement solely among the shareholders of the Corporation and the subscribers for shares to be issued, relating to the control of any phase of the business and affairs of the Corporation, its liquidation and dissolution, or the relations among shareholders of or subscribers to shares of the Corporation is valid and specifically enforceable as provided in this Article. 5.2. Method of Approval. A written agreement solely among persons described in Section 5.1 above that relates to the control of or the liquidation and dissolution of the Corporation, the relations among them, or any phase of the business and affairs of the Corporation (including, without limitation, the management of its business, the declaration and payment of distributions, the election of directors or officers, the employment of shareholders by the Corporation, or the arbitration of disputes) is valid and specifically enforceable, if the agreement is signed by all persons who are then the shareholders of the Corporation, whether or not the shareholders all have voting shares, and the subscribers for shares, whether or not voting shares, to be issued. 5.3. Enforceability. The agreement is enforceable by the persons described in Section 5.1 who are parties to it and is binding upon and enforceable against only those persons and other persons having knowledge ofthe existence of the agreement. 5.4. Liability. The effect of an agreement authorized by this Article is to relieve the board and the director or directors in their capacities as directors, and to impose upon the parties to the agreement, the liability for acts or omissions imposed by law upon directors to the extent that and so long as the discretion or powers of the directors in the management of the business and affairs of the Corporation are exercised 5 by the shareholders under a provision in the agreement. However, a shareholder is not liable pursuant to this Section 5.4 by virtue ofa shareholder vote, if the shareholder had no right to vote on the action, 5.5. Copies. A copy of the agreement shall be filed with the Corporation. The existence and location of a copy of the agreement shall be noted conspicuously on the face or back of each certificate for shares issued by the Corporation and on each transaction statement. A shareholder, a beneficial owner of shares, or another person having a security interest in shares has the right upon written demand to obtain a copy of the agreement from the Corporation at the expense ofthe Corporation. 5.6. Other Agreements. This Article does not apply to, limit, or restrict agreements otherwise valid, The procedures set forth in this Article shall not be construed as the exclusive method of agreement among shareholders, or between the shareholders and the Corporation, with respect to any of the matters described in this Article. ARTICLE VI Miscellaneous 6.1. Control Share Acquisitions. The Corporation hereby expressly elects not to be subject to the "control share acquisition" provisions of the MBCA. 6.2. Business Combinations. The Corporation hereby expressly elects not to be subject to the "business ,/ combination" provisions of the MBCA. ARTICLE VII Effective Date of Articles 7.1. Filing of Articles. These Articles of Incorporation shall be effective when they are filed with the Minnesota Secretary of State. 7.2. Corporate Existence Begins. The existence of this Corporation shall begin when these Articles of Incorporation are filed, ARTICLE VITI Incorporator 8.1. Name and Address. The name and address of the incorporator ofthe Corporation are as follows: Lisa Montague Ingalls, Esq. 6600 France Avenue S" Suite 510 Edina, MN 55435 / 6 8.2. Powers. Until the directors are elected, the incorporator shall manage the affairs of the Corporation and may do whatever is necessary to perfect the organization of the Corporation, including the adoption of the original by-laws of the Corporation and the election of directors. IN WITNESS WHEREOF, the undersigned has hereunto executed these Articles of Incorporation on June 30, 2003. / i dTATE OF MINNl::::;U it-. DEPARTMENT OF STATE FILED JUN 30 2003 '11f. IItlf"r' I tWf . qecretarv ,..,f C'.- ~ 7 APPENDIX C Bylaws AMENDED AND REST A TED DYLA WS OF F.e. OF GEORGIA, INC. 1180960.1 ARTICLE I 1.1, 1.2, ARTICLE 2 2, I. 2,2, 2.3. 2.4. 2.5. 2.6. 2.7. 2.8. 2.9. 2.10. 2.11. ARTICLE 3 3.1. 3.2. 3.3. 3.4. 3.5. 3.6. 3.7. 3.8. 3,9. 3.10. 3.11. 3.12. 3.13. ARTICLE 4 4.1. 4.2. 4.3. 4.4. 4.5. 4.6. 4.7. 4.8. 4.9. 4.10. ARTICLE 5 5.1. 5.2. 5.3. 1180960.1 TABLE OF CONTENTS Offices ........................................................ .................... .............. ................ ........... I Registered Office......................,.............................. ............,.....,.............,.............' I Other Offices............................................................................................,.............. I Meetings of Shareholders...............................................,.. ...................................... I Place of Meeting ....... ,....,.. ... ,..,... ...., ..,..........,............ .........., ..., ...., .....,... ,..., ,.......,.. I Regular Meetings. .........., ........ ,.......,............. ,...,........ ....... ..., ........ ... ........,..,........... I Special Meetings.. ...... ...................... ...... ..... .................................. .......................... I Notice of Meetings and Waiver of Notice ...................................;.......................... 2 Record Date..................,........,...................................,....."................,.......,........,.... 3 Quorum ................................................................................................................... 3 Voting and Proxies .................................................................................................. 4 Action Without Meeting by Shareholders............................................................... 4 Attendance at Shareholder Meetings ...................................................................... 4 Remote Communications for Shareholders Meeting ..............................................5 Rules of Procedure........................................................,.......................,................. 5 Directors..........,........................................... .......,...,................................................ 5 General Powers............................. .......... .......... ....................................... ............... 5 Number, Tenure and Qualification ......................................................................... 5 Meetings..................................,......................... ......;............, .............. ,................... 6 Notice of Meetings ................................... ................................ ............................... 6 Quorum ....... ,.,...,............,...... ........,.........,.....,......................................,................... 6 Voting.......... ......'......., ....,...... .., .......,....................... ..,.........................,................,.. 7 Vacancies and Newly Created Directorships.......................................................... 7 Removal of Directors ................................................... ........., ................................. 7 Action in Writing .................,........,................,.......,........................................,.......7 Meeting by Remote Communication ...................................................................... 8 Committees ............................................................................ ..............,.............. ,... 8 Attendance at Director Meetings ............................................................................ 8 Chair of the Board.................................................................,......,... ...... ................. 8 Officers............... .........,................................ .... ........... .............. .............................. 9 Number and Qualification..............,..........................................,............................. 9 Term of Office..........................,.............................. ..., ............................................ 9 Removal and Vacancies ..........................................................................................9 Chief Executive Officer............................,........................................,.....,.............. 9 Chief Financial Officer......................................,.................................................... 9 President............ ............. ............... ........... ....................... ................... .............. ..... 10 Vice President(s). ....................................,..... ...,...................... ,.. ,.......,... ,.............. 10 Secretary......................,....,....................................,..,..,...........,............................. 10 Treasurer.............. ...................... .......................... .............. ..................... .............. 10 Delegation .........,.....................................,..........................................:...,.............. 10 Certificates and Ownership of Shares................................................................... 10 Certificates................................................................. ........................................... 10 Transfer of Shares ...................................:............................................................. II Ownership ...........................................................,..................................,............., 11 ARTICLE 6 6.1. 6.2. 6.3. 6.4. ARTICLE 7 ARTICLE 8 8.1. 8.2. 8.3. 8.4. 8.5. 8.6. 1180960.1 Contracts, Loans, Checks, and Deposits ............................................................... ] 1 Contracts ............................................................................................................... ] 1 Loans .................. .................. ......................... ................ .................. .............. ........ ] 2 Checks, Drafts, etc ................................................................................................ 12 Deposits................. ................................................................................................ 12 Indemnification of Certain Persons.......................................................... ............. 12 Miscellaneous........................................................................................................ 12 Dividends .............................................................................................................. 12 Reserves ........................................................... ........................................... .......... 13 Fiscal Year ............................................................................................................13 Amendments ......... ..... .......... .................................. .... ..... .............. ......... ..... .......... 13 Shareholder Agreements ................................................. ................. ........... .......... 13 Definitions............................................................................................................. 13 2 AMENDED AND RESTATED BYLAWS OF F.C. OF GEORGIA, INC. ARTICLE 1 Offices 1.1. Registered Office. The registered office of the corporation shall be located within the State of Minnesota as set forth in the Articles of Incorporation (as defined in Section 8.6). The registered office need not be identical with the principal executive office of the corporation and may be changed from time to time by the Board of Directors. 1.2. Other Offices. The corporation may have other offices at such places inside and outside the State of Minnesota as the Board of Directors may determine from time to time. ARTICLE 2 Meetings of Shareholders 2.1. Place of Meeting. All meetings of the shareholders of this corporation shall be held at its principal executive office unless some other place for any such meeting inside or outside the State of Minnesota is designated by the Board of Directors in the notice of meeting or the meeting is held by remote communication (as defined in Section 8.6) pursuant to Section 2.10. Any regular or special meeting of the shareholders of the corporation called by or held pursuant to a written demand of shareholders shall be held in the county where the principal executive office of the corporation is located. 2.2. Regular Meetings. Regular meetings of the shareholders of this corporation may be held at the discretion of the Board of Directors on an annual or less frequent periodic basis. The date, time and place of such meetings shall be designated by the Board of Directors in the notices of meeting. At regular meetings the shareholders shall elect a Board of Directors and transact such other business as may be appropriate for action by shareholders. If a regular meeting of shareholders has not been held for a period of 15 months, one or more shareholders holding not less than 3% of the voting power of all shares of the corporation entitled to vote may call a regular meeting of shareholders by delivering to the Chief Executive Officer or Chief Financial Officer a written demand for a regular meeting. Within 30 days after the receipt of such a written demand by the Chief Executive Officer or Chief Financial Officer, the Board of Directors shall cause a regular meeting of shareholders to be called. Such a meeting shall be . held on notice no later than 90 days after the receipt of such written demand, all at the expense of the corporation. 2.3. Special Meetings. Special meetings of the' shareholders, for any purpose or purposes appropriate for action by shareholders, may be called by the Chief Executive Officer, by the acting Chief Executive Officer in the absence of the Chief Executive Officer, by the Chief Financial Officer, the Chair of the Board, or by two Or more members of the Board of Directors. The date, time, and place of such special meeting shall be fixed by the person or persons calling the meeting and designated in the notice of meeting. 1180960.1 A special meeting may also be called by one or more shareholders holding 10% or more of the voting power of all shares of the corporation entitled to vote, except that a special meeting for the purpose of considering any action to directly or indirectly facilitate or effect a business combination, including any action to change or otherwise affect the composition of the Board of Directors for that purpose, when called by shareholders, must be called by shareholders holding 25% or more of the voting power of all shares entitled to vote. The shareholders calling such meeting shall deliver to the Chief Executive Officer or Chief Financial Officer a written demand for a special meeting. Such a demand shall contain the purpose or purposes of the meeting. Within 30 days after the receipt of such a written demand for a special meeting of shareholders by the Chief Executive Officer or Chief Financial Officer, the Board of Directors shall cause a special meeting of shareholders to be called. Such a meeting shall be held on notice no later than 90 days after the receipt of such written demand, all at the expense of the corporation. Business transacted at any special meeting of the shareholders shall be limited to the purpose or purposes stated in the notice of the meeting. Any business transacted at any special meeting of the shareholders that is not included among the stated purposes of such meeting shall be voidable by or on behalf of the corporation unless all of the shareholders have waived notice of the meeting. 2.4. Notice of Meetings and Waiver of Notice. Except when a meeting of shareholdcrs is an adjourned meeting to be held not more than 120 days after the date fixed for the original meeting and the date, time, and place of such meeting were announced at the time of the original meeting or any adjournment of the original meeting, notice of all meetings shall be given to every holder of shares entitled to vote. Such notice shall contain the date, time, and place of the shareholder meeting and any other information required by law. In the case of a special meeting, the notice shall contain a statement of the purposes of the meeting. The notice may also contain any other information deemed necessary or desirable by the Board of Directors or by any other person or persons calling the meeting. Unless a different minimum notice period has been fixed by law, the Articles of Incorporation, or these Bylaws, notice of all meetings, including meetings for consideration of the sale or other disposition of all or substantially all of the assets of the corporation, shall be given not less than three nor more than 60 days before the date of the meeting. In the event that a plan of merger or exchange is to be considered at a meeting of shareholders, written notice of such meeting shall be given to every shareholder, whether or not entitled to vote, not less than 14 nor more than 60 days before the date of the meeting. Such a notice shall contain the date, time, and place of the shareholder meeting, shall state that a purpose of such meeting is to consider the proposed plan of merger or exchange, and shall include a copy or a short description of the plan of merger or exchange. Notice of all meetings shall be given to each eligible shareholder either by oral communication, by mailing a copy of the notice to an address designated by the shareholder or to the last known address of the shareholder, by handing a copy to the shareholder, or by any other delivery that conforms to law, including, without limitation, electronic communication (as IJ8Q96().! 2 defined in Section 8.6) if consent is given by a shareholder. Notice shall be deemed received when it is given. Notice by mail shall be deemed given when deposited in the United States mail with sufficient postage affixed. Notice by electronic communication shall be deemed given (I) if by facsimile communication, when directed to a telephone number at which the shareholder has consented to receive notice; (2) if by electronic mail, when directed to an electronic mail address at which the shareholder has consented to receive notice; (3) if by a posting on an electronic network on which the shareholder has consented to receive notice, together with separate notice to the shareholder of specific posting, upon the later of: (i) the posting; or (ii) the giving of separate notice; and (4) if by any other form of electronic communication by which the shareholder has consented 10 receive notice, when directed to the shareholder. Consent by a shareholder to notice given by electronic communication may be given in writing or by authenticated (as defined in Section 8.6) electronic communication. The corporation is entitled to rely on any consent so given until revoked by the shareholder, provided that no revocation affects the validity of any notice given before receipt by the corporation of revocation of the consent. Any shareholder may waive notice of any meeting of shareholders. Waiver of notice shall be effective whether given before, at, or after the meeting and whether given orally, in writing, or by attendance. Attendance by a shareholder at a meeting is a waiver of notice of thai meeting, except when such shareholder objects at the beginning of the meeting to the transaction of business because the meeting is not lawfully called or convened or objects before a vole on an item of business because the item may not lawfully be considered at that meeting and does not participate in the consideration of the item at the meeting. 2.5. Record Date. The Board of Directors may fix, or authorize an officer to fix, a date not more than 60 days before the date of a meeting of shareholders as the date for the determination of the holders of shares entitled to notice of and entitled to vote at any meeting. When a date is so fixed, only shareholders on that date are entitled to notice of and permitted to vote at that meeting of shareholders. 2.6. Quorum. The holders of a majority of the voting power of all shares of the corporation entitled to vote at a meeting, present in person or represented by proxy, shall constitute a quorum for the transaction of business at a meeting of the shareholders. Such a quorum is a prerequisite to the shareholders taking any action other than adjournment. In the absence of a quorum, the holders of a majority of the voting power, present in person or represented by proxy, may adjourn the meeting to a date, time, and place they shall announce at the time of adjournment. Any business Ihat might have been transacted at the adjourned meeting had a quorum been present, may be transacted at the meeting held pursuant to such an adjournment, if a quorum is present at the meeting held pursuant to such an adjournment. If a quorum is present when a duly called or held meeting is convened, Ihe shareholders present may continue to transact business until adjournment, even though the withdrawal of a number of shareholders originally represented leaves less than the number otherwise required for a quorum. 1180960.1 3 2.7. Voting and Proxies. At each meeting of the shareholders, every shareholder shall be entitled to one vote for each share of capital stock held by such shareholder, except as may be otherwise provided in the Articles of Incorporation or by the terms of the share or as may be required to provide for cumulative voting (if not denied by the Articles oflncorporation). A shareholder may vote in person or by proxy. A shareholder may cast, or authorize the casting of, a vote (I) in person, (2) by filing a written appointment of a proxy, signed by the shareholder, with an officer of the corporation at or before the meeting at which the appointment is to be effective, or (3) if authorized by the Board of Directors, by telephone, Internet, authenticated electronic communication, or any other manner permitted by law. The appointment of a proxy shall be valid for no more than 11 months, unless a longer period is expressly provided in the appointment. An appointment of a proxy for shares held jointly by two or more shareholders shall be valid if signed by anyone of them, unless the Secretary of the corporation receives from anyone of such shareholders written notice either denying the authority of that shareholder to appoint a proxy or appointing a different proxy. All questions regarding the qualification of voters, the validity of appointments of proxies, and the acceptance or rejection of votes shall be decided by the inspector of election. The shareholders shall take action by the affirmative vote of the holders of a majority of the voting power of the shares present and entitled to vote, except when a different vote is required by law, the Articles of Incorporation, or these Bylaws. Notwithstanding the preceding sentence, directors are elected by a plurality of the voting power of the shares present and entitled to vote on the election of directors at a meeting at which a quorum is present, unless the Articles of Incorporation provide otherwise. 2.8. Action Without Meeting by Shareholders. Any action required or permitted to be taken at a meeting of the shareholders may be taken without a meeting by written action signed, or consented to by authenticated electronic communication, by all of the shareholders entitled to vote on such action. However, if the Articles of Incorporation authorize written action by less than all the shareholders, such action may be taken by written action signed, or consented to by authenticated electronic communication, by the number of sbareholders that would be required to take the same action at a meeting of the shareholders at which all shareholders were present. If any written action is taken by less than all shareholders, the corporation must notify all shareholders within five days of the effective time of its text and effective date. The failure to provide such notice, however, will not invalidate such written action. A shareholder who does not sign or consent to the written action has no liability for the action or actions taken thereby. Such written action shall be effective when signed, or consented to by authenticated electronic communication, by the required shareholders entitled to vote thereon, unless a different effective time is provided in the written action. 2.9. Attendance at Shareholder Meetings. The authority of anyone other than shareholders (or their duly authorized attorney-in-fact), proxy holders, or persons invited by the Board of Directors to attend any meeting of the shareholders shall be determined by the sole discretion of the Board, or by the affirmative vote of the holders of a majority of the voting power of the shares present and entitled to vote. Any action taken by the shareholders at a meeting at which an unauthorized person is in attendance is not void or voidable. llSQ960.1 4 2.10. Remote Communications for Shareholders Meeting. The Board of Directors is authorized to hold regular or special meetings of the shareholders solely by means of remote communication through which the shareholders may participate in the meeting, if notice of the meeting is given to every holder of shares entitled to vote at such meeting, and if the number of shares held by the shareholders participating in the meeting would be sufficient to constitute a quorum at the meeting. Furthermore, the Board of Directors is authorized to determine that a shareholder not physically present in person or by proxy at a regular or special meeting of shareholders may, by means of remote communication, participate in a meeting of shareholders held at a designated place. In any meeting of shareholders held solely by means of remote communication or in any meeting of shareholders held at a designated place in which one Or more shareholders participate by means of remote communication, the cOlporation must implement reasonable measures to verify that each person deemed present and entitled to vote at the meeting by means ofremote communication is a shareholder, proxy holder or person invited by the Board of Directors. In addition, the corporation must implement reasonable measures to provide each shareholder participating by means of remote communication with a reasonable opportunity to participate in the meeting, including an opportunity to: (1) read or hear the proceedings of the meeting substantially concurrently with those proceedings; (2) if allowed by the procedures governing the meeting, have the shareholder's remarks heard or read by other participants in the meeting substantially concurrently with the making of those remarks; and (3) if otherwise entitled, vote on matters submitted to the shareholders. 2.11. Rules of Procedure. The Board of Directors may adopt rules of procedure for conducting meetings of shareholders, provided such rules are not inconsistent with the Articles of Incorporation, these Bylaws or law. In the absence of rules adopted by the Board of Directors, the Chair may establish rules of procedure for conducting meetings of shareholders, provided such rules are not inconsistent with the Articles of Incorporation, these Bylaws or law. ARTICLE 3 Directors 3.1. General Powers. Except as authorized by the shareholders pursuant to a shareholder control agreement or unanimous affirmative vote by the holders of shares entitled to vote for directors of the corporation, the business and affairs of the corporation shall be managed by or under the direction of its Board of Directors. The Board of Directors may exercise all such powers and do all such things as may be exercised or done by the corporation, subject to the provisions of law, the Articles ofIncorporation, and these Bylaws. 3.2. Number, Tenure and Qualification. The number of directors which shall constitute the whole Board of Directors shall be fixed from time to time by resolution of the shareholders, subject to increase by resolution of the Board of Directors. In the event that the shareholders fail to fix the number of directors, the number of directors shall be the number which constituted the initial Board of Directors, subject to increase by resolution of the Board of Directors. No decrease in the number of directors pursuant to this Section 3.2 shall effect the removal of any director then holding office except upon compliance with the provisions of Section 3.8 of these Bylaws. Each director shall be elected at a regular meeting of shareholders except as provided in Sections 3.7 and 3.8. Such a director shall hold office until the next regular meeting of ]]80960.1 5 shareholders and thereafter until a successor is duly elected and qualified. Directors shall be natural persons, but need not be shareholders. 3.3. Meetings. Meetings of the Board of Directors may be held at such times and places, or solely by one or more means of remote communication, as shall from time to time be determined by the Board of Directors. Meetings of the Board of Directors also may be called by the Chair of the Board, the Chief Executive Officer, by the acting Chief Executive Officer in the absence of the Chief Executive Officer or by two or more members of the Board of Directors. 3.4. Notice of Meetings. If the date, time, and place of a meeting of the Board of Directors have been announced at a previous meeting, no notice is required. In all other cases, notice of meetings shall be given to each member of the Board of Directors by the person or persons calling such meeting. Such notice shall contain the date, time, and place of the meeting and any other information reqnired by law or desired by the person or persons calling such meeting. Notice of all such meetings shall be given not less than 48 hours before the date of the meeting. Notice of all meetings shall be given to each director either by oral communication, by mailing a copy of the notice to an address designated by the director, by handing a copy to the director, or by any other delivery that conforms to law, including, without limitation, electronic communication if consent is given by a director. Notice shall be deemed received when it is given. Notice by mail shall be deemed given when deposited in the United States mail with sufficient postage affixed. Notice by electronic communication shall be deemed given (I) ifby facsimile communication, when directed to a telephone number at which the director has consented to receive notice; (2) if by electronic mail, when directed to an electronic mail address at which the director has consented to receive notice; and (3) if by any other form of electronic communication by which the director has consented to receive notice, when directed to the director. Consent by a director to notice given by electronic communication may be given in writing or by authenticated (as defined in Section 8.6) electronic communication. The corporation is entitled to rely on any consent so given until revoked by the director, provided that no revocation affects the validity of any notice given before receipt by the corporation of revocation of the consent. A director may waive notice of any meeting of the Board of Directors. A waiver of notice by a director is effective whether given before, at, or after the meeting, and whether given orally, in writing, by authenticated electronic communication, or by attendance. Attendance by a director at a meeting is a waiver of notice of that meeting, except when such director objects at the beginning of the meeting to the transaction of business because the meeting is not lawfully called or convened and does not participate thereafter in the meeting. 3.5. Quorum. A majority of the directors currently holding office shall constitute a quorum for the transaction of business at any meeting of the Board of Directors. In the absence of a quorum, a majority of the directors present at the meeting may adjourn the meeting from time to time until a quorum is present. 1[80960.1 6 If a quorum is present when a duly called or held meeting is convened, the directors present at the meeting may continue to transact business until adjournment, even though the withdrawal of a number of directors originally present leaves less than the number otherwise required for a quorum. 3.6. Voting. The Board of Directors shall take action by the affirmative vote of the greater of (x) a majority of the directors present at any duly held meeting at the time the action is taken or (y) a majority of the minimum proportion or number of directors that would constitute a quorum for the transaction of business at the meeting, except when a different vote is required by law, the Articles ofIncorporation, or these Bylaws. A director may give advance written consent or objection to a proposal to be acted upon at a meeting of the Board of Directors. If the director is not present at the meeting, consent or objection to a proposal does not constitute presence for purposes of determining a quorum, but consent or objection shall be counted as a vote of a director present at the meeting in favor of or against the proposal and shall be entered in minutes or other record of action at the meeting, if the proposal acted upon at the meeting is substantially the same or has substantially the same effect as the proposal to which the director has consented or objected. 3.7. Vacancies and Newly Created Directorships. Any vacancy occurring on the Board of Directors resulting from the death, resignation, retirement, disqualification, removal, or other cause (including a vacancy due to an increase in the number of authorized directors) may be filled by the affirmative vote of a majority of the directors then holding office, even if less than a quorum. Any vacancy or newly created directorship may be filled by resolution of the shareholders. Each director elected by the Board of Directors to either fill a vacancy or a newly created directorship shall hold office until a qualified successor is elected by the shareholders at the next regular or special meeting of the shareholders. 3.8. Removal of Directors. Anyone or all of the directors may be removed at any time, with or without cause, by the affirmative vote of the holders of the proportion or number of the voting power of the then outstanding shares of capital stock of the corporation entitled to vote for the election of such director unless cumulative voting is permitted, in which case the affirmative vote required to remove a director shall be the larger number required by law. The shareholders may elect new directors at the same meeting at which directors are removed. In addition, any director may be removed at any time, with or without cause, by the other members of the Board of Directors if (a) the director was appointed by the board to fill a vacancy; (b) the shareholders have not elected directors in the interval between the time of the appointment and the time of removal; and (c) a majority of the remaining directors present affirmatively vote to remove the director, even though said remaining directors may be less than a quorum. 3.9. Action in Writing. Any action required or permitted to be taken at a meeting of the Board of Directors that requires the approval of the shareholders, may be taken by written action signed, or consented to by authenticated electronic communication, by all of the directors then holding office. However, if the Articles of Incorporation authorize written action by less than all the directors and the action does not require shareholder approval, such action may be taken by written action signed, or consented to by authenticated electronic communication, by 1180960.1 7 the number of directors that would be required to take the same action at a meeting of the Board of Directors at which all directors were present. If any written action is taken by less than all directors, all directors shall be notified immediately of its text and effective date. The failure to provide such notice, however, shall not invalidate such written action. A director who does not sign or consent to the written action has no liability for the action or actions taken thereby. Such written action shall be effective when signed, or consented to by authenticated electronic communication, by the required number of directors, unless a different effective time is provided in the written action. 3.10. Meeting by Remote Communication. A director may participate in a board meeting by means of conference telephone or, if authorized by the Board of Directors, by such other means of remote communication, in each case through which the director, other directors so participating, and all directors physically present at the meeting may participate with each other during the meeting. Participation in a meeting by that means constitutes presence at the meeting. 3.11. Committees. The Board of Directors, by a resolution approved by the affirmative vote of a majority of the directors then holding office, may establish one or more committees of one or more persons. Such committees shall have the authority of the Board of Directors in the management of the business of the corporation only to the extent provided in the authorizing resolution. Such committees, other than special litigation committees and conunittees formed pursuant to Minnesota Statutes Section 302A.673, subdivision l(d) (or any similar provision of future law), shall at all times be subject to the direction and control of the Board of Directors. Committee members need not be directors and shall be appointed by the affirmative vote of a majority of the directors present at any duly held meeting. A majority of the members of any committee shall constitute a quorum for the transaction of business at a meeting of any such committee. In other matters of procedure, the provisions of these Bylaws shall apply to committees and the members thereof to the same extent they apply to the Board of Directors and directors. This shall include, without limitation, the provisions with respect to meetings and notice thereof, absent members, written actions, and valid acts. Each committee shall keep regular minutes of its proceedings and report the same to the Board of Directors. 3.12. Attendance at Direelor Meetings. The authority of anyone other than directors or persons invited by the Board of Directors to attend any meeting ofthe Board of Directors shall be determined by the sole discretion of the Board of Directors. Any action taken by the Board of Directors at a meeting at which an unauthorized person is in attendance is not void or voidable. 3.13. Chair ofthe Board. The Board of Directors may elect a Chair of the Board who, if elected, shall preside at all meetings of the shareholders and of the Board of Directors and shall perform such other duties as may be prescribed by the Board of Directors from time to time. The Chair of the Board shall not be deemed to be an officer or employee of the corporation solely by serving as the Chair ofthe Board. 8 118D960-1 ARTICLE 4 Officers 4.1. Number and Qualification. The officers of the corporation shall consist of one or more natural persons elected or appointed by the Board of Directors exercising the functions of the offices, however designated, of Chief Executive Officer and Chief Financial Officer. The Board of Directors may also elect or appoint such other officers and assistant officers as it may deem necessary for the operation and management of the corporation. Except as provided in these Bylaws, the Board of Directors shall fix the powers, duties, and compensation of all officers. Officers may be, but need not be, directors of the corporation. Any number of offices may be held by the same person. 4.2. Term of Office. An officer shall hold office until a successor shall have been duly elected, unless prior thereto such officer shall have resigned or been removed from office as hereinafter provided. 4.3. Removal and Vacancies. Any officer elected or appointed by the Board of Directors shall hold office at the pleasure of the Board of Directors and may be removed at any time, with or without cause, by a resolution approved by the affirmative vote of a majority of the members of the Board of Directors present at a duly called and held meeting. Any vacancy in an office of the corporation shall be filled by action of the Board of Directors. 4.4. Chief Executive Officer. Unless provided otherwise by a resolution adopted by the Board of Directors, the Chief Executive Officer shall have general active management of the business of the corporation, in the absence of the Chair of the Board or if the office of Chair of the Board is vacant, shall preside at meetings of the shareholders and the Board of Directors, shall see that all orders and resolutions ofthe Board of Directors are carried into effect, shall sign and deliver in the name of the corporation any deeds, mortgages, bonds, contracts, or other instrurnenrs pertaining to the business of the corporation, except in cases in which the authority to sign and deliver is required by law to be exercised by another person or is expressly delegated by the Articles of Incorporation, these Bylaws, or the Board of Directors to some other officer or agent of the corporation, may maintain records of and certify proceedings of the Board of Directors and shareholders, and shall perform such other duties as may from time to time be prescribed by the Board of Directors. 4.5. Chief Financial Officer. Unless provided otherwise by a resolution adopted by the Board of Directors, the Chief Financial Officer shall keep accurate financial records for the corporation, shall deposit all moneys, drafts, and checks in the name of and to the credit of the corporation in such banks and depositories as the Board of Directors shall designate from time to time, shall endorse for deposit all notes, checks, and drafts received by the corporation as ordered by the Board of Directors, making proper vouchers therefor, shall disburse corporate funds and issue checks and drafts in the name of the corporation as ordered by the Board of Directors, shall render to the Chief Exec\ltive Officer and the Board of Directors, whenever requested, an account of all such officer's transactions as Chief Financial Officer and of the financial condition of the corporation, and shall perform such other duties as may be prescribed by the Board of Directors or the Chief Executive Officer from time to time. ]]80960.1 9 4.6. President. Unless otherwise determined by the Board of Directors, the President shall be the Chief Executive Officer of the corporation. If an officer other than the President is designated Chief Executive Officer, the President, if any, shall have such powers and perform such duties as the Board of Directors or the Chief Executive Officer may prescribe from time to time. 4.7. Vice President(s). The Vice President, if any, or Vice Presidents in case there be more than one, shall have such powers and perform such duties as the Board of Directors or the Chief Executive Officer may prescribe from time to time. In the absence of the President or in the event of the President's death, inability, or refusal to act, the Vice President, or in the event there be more than one Vice President, the Vice Presidents in the order designated by the Board of Directors, or, in the absence of any designation, in the order of their election, shall perform the duties of the President, and, when so acting, shall have all the powers of and be subject to all of the restrictions upon the President. 4.8. Secretary. The Secretary shall attend all meetings of the Board of Directors and of the shareholders and shall maintain records of, and whenever necessary, certify all proceedings of the Board of Directors and of the shareholders. The Secretary shall keep the stock books of the corporation, when so directed by the Board of Directors or other person or persons authorized to call such meetings, shall give or cause to be given notice of meetings of the shareholders and of meetings of the Board of Directors, and shall also perform such other duties and have such other powers as the Board of Directors or the Chief Executive Officer may prescribe from time to time. 4.9. Treasurer. Unless otherwise determined by the Board of Directors, the Treasurer shall be the Chic{ Financial Officer of the corporation. If an officer other than the Treasurer is designated Chief Financial Officer, the Treasurer, if any, shall have such powers and perform such duties as the Board of Directors or the Chief Executive Officer may prescribe from time to time. 4.10. Delegation. Unless prohibited by a resolution approved by the affirmative vote of a majority of the directors present, an officer elected or appointed by the Board of Directors may, without the approval of the Board of Directors, delegate some or all of tbe duties and powers of such person's office to other persons. ARTICLE 5 Certificates and Ownership of Shares 5.1. Certificates. All shares of the corporation shall be represented by certificates. Each certificate shall contain on its face (a) the name of the corporation, (b) a statement that the corporation is incorporated under the laws of the State of Minnesota, (c) the name of the person to whom it is issued, and (d) the number and class of shares, and the designation of the series, if any, that the certificate represents. Certificates shall also contain any other information required by law or desired by the Board of Directors, and shall be in such form as shall be determined by the Board of Directors. Such certificates shall be signed by the Chief Executive Officer, by the Chief Financial Officer, or, unless otherwise limited by resolution of the Board of Directors, by any other officer 1 1 8096{). I 10 of the corporation. If a certificate is signed (I) by a transfer agent or an assistant transfer agent or (2) by a transfer clerk acting on behalf of the corporation and a registrar, the signature of any such officer of the corporation may be a facsimile signature. If a person signs or has a facsimile signature placed upon a certificate while an officer, transfer agent, or registrar of a corporation, the certificate may be issued by the corporation, even if the person has ceased to have that capacity before the certificate is issued, with the same effect as if the person had that capacity at the date of its issue. All certificates for shares shall be consecutively numbered or otherwise identified. If the Articles of Incorporation establish more than one class or series of shares or authorize the Board of Directors to establish classes or series of shares, all certificates representing such shares shall set forth on the face or back of the certificate or shall state that the corporation will furnish to any shareholder upon request and without charge, a full statement of the designations, preferences, limitations, and relative rights of the shares of each class or series authorized to be issued, so far as they have been determined, and the authority of the Board of Directors to determine the relative rights and preferences of subsequent classes or series. All certificates surrendered to the corporation or the transfer agent for transfer shall be cancelled, and no new certificate shall be issued until the former certificate for a like number of shares shall have been surrendered and cancelled, except that in case of a lost, destroyed, or mutilated certificate, a new certificate may be issued therefor upon such terms and indemnity to the corporation as the Board of Directors may prescribe. 5.2. Transfer of Shares. The transfer of shares of the corporation shall be made only on the stock transfer books of the corporation by the holder of record thereof or by such holder's legal representative, who shall furnish proper evidence of authority to transfer, or by such holder's attorney thereunto authorized by power of attorney duly executed and filed with the Secretary of the corporation, and on surrender of such shares to the corporation or the transfer agent of the corporation. 5.3. Ownership. Except as otherwise provided in this Section, the person in whose name shares stand on the books of the corporation shall be deemed by the corporation to be the owner thereof for all purposes. The Board of Directors, however, by a resolution approved by the affirmative vote of a majority of directors then holding office, may establish a procedure whereby a shareholder may certify in writing to the corporation that all or a portion of the shares registered in the name of such shareholder are held for the account of one or more beneficial owners. Upon receipt by the corporation of the writing, the persons specified as beneficial owners, rather than the actual shareholder, shall be deemed the shareholders for such purposes as are permitted by the resolution ofthe Board of Directors and are specified in the writing. ARTICLE 6 Contracts, Loans, Checks, and Deposits 6.1. Contracts. The Board of Directors may authorize such officers or agents as they shall designate to enter into contracts or execute and deliver instruments in the name of and on behalf of the corporation, and such authority may be general or confined to specific instances. 1180960.] 11 6.2. Loans. The corporation shall not lend money to, guarantee the obligation of, become a surety for, or otherwise financially assist any person unless the transaction, or class of transactions to which the transaction belongs, has been approved by the affirmative vote of a majority of directors present at a duly called and held meeting, and (a) is in the usual and regular course of business of the corporation, (b) is with, or for the benefit of, a related corporation, an organization in which the corporation has a financial interest, an organization with which the corporation has a business relationship, or an organization to which the corporation has the power to make donations, (c) is with, or for the benefit of, an officer or other employee of the corporation or a subsidiary, including an officer or employee who is a director of the corporation or a subsidiary, and may reasonably be expected, in the judgment of the Board of Directors, to benefit the corporation, or (d) whether or not any separate consideration has been paid or promised to the corporation, has been approved by (i) the affirmative vote of the holders of two- thirds of the voting power of the shares entitled to vote which are owned by persons other than the interested person or persons or (ii) the unanimous affirmative vote of the holders of all outstanding shares, whether or not entitled to vote. 6.3. Checks, Drafts, etc. All checks, drafts or other orders for the payment of money, notes, or other evidences of indebtedness issued in the name of the corporation shall be signed by such officers or agents of the corporation as shall be designated and in such manner as shall be determined from time to time by resolution of the Board of Directors. .6.4. Deposits. All funds of the corporation not otherwise employed shall be deposited from time to time to the credit of the corporation in such banks or other financial institutions as the Board of Directors may select. ARTICLE 7 Indemnification of Certain Persons The corporation shall indemnifY all officers and directors of the corporation, for such expenses and liabilities, in such manner, under such circumstances and to such extent as permitted by Minnesota Statutes Section 302A.52I , as now enacted or hereafter amended (or any similar provision of future law). The Board of Directors may authorize the purchase and maintenance of insurance and/or the execution of individual agreements for the purpose of such indemnification, and the corporation shall advance all reasonable costs and expenses (including attorneys' fees) incurred in defending any action, suit or proceeding to all persons entitled to indemnification under this Article 7, all in the manner, under the circumstances and to the extent permitted by Minnesota Statutes Section 302A.521, as now enacted or hereafter amended (or any similar provision of future law). Unless otherwise approved by the Board of Directors, the corporation shall not indemnifY any employee of the corporation who is not otherwise entitled to indemnification pursuant to this Article 7, except as may be required by law. ARTICLE 8 Miscellaneous 8.1. Dividends. The Board of Directors from time to time may declare, and the corporation may pay, dividends on its outstanding shares in the manner and upon the terms and conditions provided by law. 1180%0.1 12 8.2. Reserves. There may be set aside out of any funds of the corporation available for dividends such sum or sums as the Board of Directors from time to time, in its absolute discretion, deems proper as a reserve or reserves to meet contingencies, for equalizing dividends, for repairing Or maintaining any property of the corporation, for the purchase of additional property, or for such other purpose as the directors shall deem to be consistent with the interests of the corporation. The Board of Directors may modifY or abolish any su~h reserve. 8.3. Fiscal Year. The Board of Directors shall determine the fiscal year of the corporation. 8.4. Amendments. The Board of Directors is expressly authorized to make bylaws of the corporation and from time to time to adopt, amend or repeal bylaws so made to the extent and in the manner prescribed in the Minnesota Statutes. The Board of Directors shall not adopt, amend, or repeal a bylaw fixing a quorum for meetings of shareholders, prescribing procedures for removing directors or filling vacancies in the Board of Directors, or fixing the number of directors or their classifications, qualifications or tenns of office, but may adopt or amend a bylaw to increase the number of directors. The authority in the Board of Directors is subject to the power of the shareholders to adopt, change or repeal the bylaws by a vote of shareholders holding a majority of the shares entitled to vote and present or represented at any regular meeting or special meeting called for that purpose. . 8.5. Shareholder Agreements. In the event of any conflict or inconsistency between these Bylaws, or any amendment thereto, whenever adopted, and the terms of any shareholder control agreement as defined in Minnesota Statutes Section 302A.457 (or similar provision of future law), the tenns of such shareholder control agreement shall control. 8.6. Definitions. The following words or phrases when used in these Bylaws have the meanings set forth below: (a) "Articles of Incorporation" means the Articles of Incorporation of the corporation, as may be subsequently amended; (b) "authenticated" means, with respect to an electronic communication, that the communication is delivered to the principal place of business of the corporation, or to an officer or agent of the corporation authorized by the corporation to receive the communication, and that the communication sets forth infonnation from which the corporation can reasonably conclude that the communication was sent by the purported sender; ( c) "electronic communication" means any fonn of communication, not directly involving the physical transmission of paper, that creates a record that may be retained, retrieved, and reviewed by a recipient of the communication, and that may be directly reproduced in paper fonn by the recipient through an automated process; and (d) Uremote communication" means communication via electronic communication, conference telephone, video conference, the Internet, or such other means by which persons not physically present in the same location may communicate with each other on a substantially simultaneous basis. 1180960.1 13 * * '" '" * CERTIFICATION The undersigned, President of F.e. of Georgia, Inc., a Minnesota corporation, does hereby certify that the foregoing Amended and Restated Bylaws are the Bylaws adopted for the cO:;F.ration by its Board of Directors and shareholders by unanimous wrillen consent dated the 30' day of January, 2006. Name: l. President ]180%0,1 14 BY-LAWS OF F.e. OF GEORGIA, INC. A corporation governed by the Minnesota Business Corporation Act TABLE OF CONTENTS 1. IDENTIFICATION 1.1. Name 1.2. Offices 1.3. Seal 2. DIRECTORS 2.1. General Powers 2.2. Number 2.3. Term of Office 2.4. Vacancies 2.5. Anoual Meeting 2.6. Special Meetings 2.7. Quorum 2.8. Actions by Absent Directors 2.9. Participation by Electronic Communication 2.10. Action Without a Meeting 3. OFFICERS 3.1. Officers Required 3.2. Term 3.3. Vacancies 3.4. President & CEO 3.5. Treasurer & CFO 3.6. Secretary 3.7. Other Officers 3.8. Transfer of Authority 3.9. Delegation by Officers 4. SHAREHOLDERS 4.1. Place of Meetings 4.2. Anoual Meeting 4.3. Special Meetings 4.4. Notice of Meetings 4.5. Quorum 4.6. Voting 4.7. Action Without a Meeting 4.8. Shareholder Management Table of Contents Page Two 5. SHARES OF STOCK 5.1. Issuance of Shares 5.2. Consideration for Shares 5.3. Certificates Representing Shares 5.4. Fractional Shares 5.5. Lost, Stolen, or Destroyed Certificates 5.6. Fixing Record Date of Share Ownership 6. LOANS AND INDEMNIFICATION 6.1. Loans and Guaranties 6.2. Indemnification 6.3. Insurance 7. CORPORATE BOOKS AND RECORDS 7.1. Required Books and Records 7.2. Financial Statements 7.3. Inspection 7.4. Copies 8. DIVIDENDS AND DISTRIBUTIONS 8.1. Distribution Defined 8.2. When Payable 8.3. Reserve Fund 9. AMENDMENT OF ARTICLES 9.1. Before Shares are Issued 9.2. After Shares are Issued 9.3. Dissenting Shareholders 10. AMENDMENT OF BY-LAWS 10.1. By the Board 10.2. By the Shareholders 10.3. Dissenting Shareholders 11. REQUIRED REPORTS 11.1. Income Tax Filings 11.2. Annual Report 11.3. Change of Registered Office BY-LAWS OF F.e. OF GEORGIA, INC. A cOqloration governed by Cbapter 302A of the laws of the State of Minnesota *************** ARTICLE I Identification 1.1. Name. The name of this Corporation is F.C. of Georgia, Inc., and all references in these By-Laws to . the Corporation are to F.C. of Georgia, Inc. 1.2. Offices. The registered office of the Corporation shall be as designated in the Articles of Incorporation. Its principal executive office shall be the place where the President & CEO of the Corporation has his or her office. In addition, the Corporation may have any other offices as the board of directors shall from time to time determine. 1.3. Seal. The Corporation may, but need not, have a corporate seal. If the Corporation does obtain a corporate seal, then the following provisions shall apply: 1.3.1. Reauirements. The seal may consist of a mechanical imprinting device, or a rubber stamp with a facsimile of the seal affixed thereon, or a facsimile or reproduction of either. The seal need include only the word "Seal". However, if desired, the seal may include (i) the name ofthe Corporation, (ii) the phrase "corporate seal," and (Hi) a designation that the Corporation is incorporated in the State of Minnesota. 1.3.2. Use of Seal. The use of the seal by the Corporation on a document is not necessary. The use or nonuse of a corporate seal shall not affect the validity, recordability, or enforceability of a document or act. It a corporate seal IS used, It or a faCSImile of it may be affixed, engraved, printed, placed, stamped with indelible ink, or in any other manner reproduced on any document. 2 ARTICLE II Directors 2.1. General Powers. The property, affairs and business of the Corporation shall be managed by or under the direction of its board of directors (except as otherwise provided in Section 4.8 of these By-Laws or the provisions of any shareholder control agreement). 2.2. Number. The board shall consist of at least one (1) director but no more than three (3) directors. The number of directors may be increased or decreased at any time by amendment of these By-Laws (pursuant to Article 10 hereof). 2.3. Term of Office. Each director shall hold office until his or her successor is duly elected and qualified, or until the director's earlier death, removal, or resignation. 2.4. Removal by Shareholders. Unless otherwise stated in the Articles of Incorporation, anyone or all of the directors may be removed at any time, with or without cause, by the affirmative vote of the holders of the proportion or number of the voting power of the shares of the classes or series the director represents sufficient to elect them. However, if the Corporation has cumulative voting, then unless the entire board is removed simultaneously, a director is not removed from the board if there are cast against removal of the director the votes of a proportion of the voting power sufficient to elect the director at an election of the entire board under cumulative voting. 2.5. Removal by Directors. A director may be removed at anytime, with or without cause, i f(i) the director was narned by the board to fill a vacancy; (ii) the shareholders have not elected directors in the interval between the time of the appointment to fill a vacancy and the time of the removal; and (iii) a majority of the remaining directors present affirmatively vote to remove the director. 2.6. Resignation. A director may resign at any time by giving written notice to the Corporation. The resignation is effective as of the time stated in the notice; but if the notice fails to specifY such a date, it is effective when received by the Corporation, whether or not the Corporation accepts the resignation. 2.7. Vacancies. Any vacancy occurring in the board of directors (whether resulting from the death, removal, or resignation of a director or directors, or as a result of newly created directorships) shall be filled by either (i) the shareholders at any duly called meeting; or (ii) the affirmative vote of a majority of the remaining directors (even though less than a quorum of the board). A director elected to fill a vacancy shall be elected for the unexpired term of that director's predecessor in office, or until that director's successor is duly elected and qualified if he had no predecessor in office. 2.8. P nnual Meeting. The board of direeters sballlllect each year immediately after the annual meeting of the shareholders. At such annual meetings, the board shall (i) elect the Corporation's officers, and (ii) consider any other business that may properly be brought before the meeting. No notice is required for any annual meeting of the board. 3 2.9. Special Meetings. A special meeting of the board of directors may be called from time to time by the President & CEO of the Corporation, or by any director of the Corporation. 2.9.1. Notice of Special Meetinl!s. No notice is required for any special meeting of the board if (i) the date, time, and place are announced at a prior meeting of the board; or (ii) the meeting is an adjourned meeting and the date, time, and place of the meeting were announced at the time of adjournment. All other meetings require written notice (by personal service, facsimile, mail, telegram, or cable). 2.9.2, Time of Notice. Any such notice shall be given at least three (3) days before the day of the meeting if the notice is given by personal service, facsimile, telegram, or cable. However, if the notice is given by mail, then that notice must be mailed at least five (5) days before the day of the meeting. 2.9.3. Contents of Notice. The notice shall contain the date, time, and place of the meeting. However, the notice need not state the purpose of the meeting. 2.9.4. Waiver of Notice. A director may waive notice of a meeting of the board. A waiver of notice by a director entitled to notice is effective whether given before, at, or after the meeting, and whether given in writing or orally. Attendance by a d irector at a meeting shall constitute a waiver of notice of that meeting unless (i) the director objects at the beginning of the meeting to the transaction of business because the meeting is not lawfully called or convened, and (ii) the director does not thereafter participate in the meeting. 2.10 Quorum. A majority of the number of directors currently holding office shall constitute a quorum for the transaction of business. Once a quorum is present, the directors may continue to transact business until adjournment (even if a number of directors withdraw so that a quorum is no longer present). The act of the majority of the directors present at a meeting at which a quorum is present shall be the act of the board of directors (unless the act of a greater number is required by the Articles of Incorporation or by statute). 2.11 Actions by Absent Directors. A director may give advance written consent or opposition to a proposal to be acted 0 n a tab oard meeting. 1 fad irector is not p resent at t he meeting, consent or opposition to a proposal does not constitute presence for purposes of determining the existence of a quorum. However, the director's consent or opposition shall be counted as a vote in favor of or against the proposal, and shall be entered in the minutes or other record of action at the meeting, if the proposal acted on at the meeting is substantially the same or has substantially the same effect as the proposal to which the director has consented or objected. 2.12 Participation by Electronic Communication. Meetings may be conducted wholly or partially by electronic means, so long as notice and quorum requirements are met. A meeting held by a telephone conference call is valid, as are all actions taken at that meeting. An individual director shall be deemed physically present at any meeting (both for quorum and voting purposes) if he or she attends that 4 meeting by telephone or other electronic means, so long as all other directors present (in person or by electronic means) can hear and speak to all other participants. 2.13 Action Witbout a Meeting. Any action that may be taken at a meeting of the directors, may be taken without a meeting if a consent in writing, setting forth the action so to be taken, shall be signed before the action by all of the directors (or any lesser number permitted by the Articles of Incorporation). Any such action is effective when it is signed by the required number of directors, unless a different effective time is provided in the written action. ARTICLE m Officers 3.1. Officers Required. The officers of the Corporation shall consist of (i) a President & CEO, (ii) a Treasurer & CFO, (iii) a Secretary, and (iv) such other officers as the board of directors may from time to time determine. The same person may hold two or more offices. 3.2. Term. Officers shall hold office for such term as the directors may specify at the time of their election or appointment. Officers shall in all cases serve until their successors are elected and qualified (or until the officer's earlier death, removal, or resignation). 3.2.1. Removal. Any officer elected or appointed by the board of directors may be removed from office, with or without cause, by the affirmative vote of a majority ofthe board of directors. 3.2.2. Resllmation. An officer may resign at any time by giving written notice to the board. The resignation is effective as of the time stated in the notice. If the notice fails to specify such a date, then the resignation i s effective when received by the board ( whe,ther 0 r n ot the board accepts the resignation). 3.3. Vacancies. Any vacancy occurring in any office (whether resulting from the death, removal, or resignation of an officer, or as a result of newly created offices) shall be filled by the affirmative vote of a majority of the board of directors. An officer elected to fill a vacancy shall be elected for the unexpired term of his predecessor in office (unless the board fixes a different term), or until his or her successor is duly elected and qualified ifhe or she had no predecessor in office. 3.4. President & CEO. The President & CEO shall be the chief executive officer of the Corporation. The President & CEO shall: (0) Ha"c genenllacti"c management of tile business of tile Corpmation; (b) Preside as chairman at all meetings of the board of directors and all meetings of the shareholders of the Corporation; (c) See that all orders and resolutions of the board are carried into effect; 5 (d) Sign and deliver in the name of the Corporation any deeds, mortgages, bonds, contracts, or other instruments pertaining to the business of the corporation (except where the authority to sign and deliver is required by law to be exercised by another person or is expressly delegated to some other officer or agent of the Corporation); and (e) Perform any and all duties prescribed by the board, 3.5. Treasurer & CFO. The Treasurer & CFO shall be the controller and the chief financial officer of the Corporation. The Treasurer & CFO shall: (a) Keep accurate financial records for the Corporation; (b) Deposit all money, drafts, and checks in the name of and to the credit of the Corporation in the banks and depositories designated by the board; (c) Endorse for deposit all notes, checks, and drafts received by the Corporation as ordered by the board, making proper vouchers therefore; (d) Disburse corporate funds and issue checks and drafts in the name 0 f t he Corporation, as ordered by the board and the President & CEO; (e) Render to the President & CEO and the board, whenever requested, an account of all transactions and of the financial condition of the Corporation; and (f) Perform any and all other duties prescribed by the board or by the President & CEO. 3.6. Secretary. The Secretary shall be the custodian of the corporate books and records which are not held by the Treasurer & CFO. The Secretary shall: (a) Attend all meetings of the shareholders and the board of directors and shall keep, or cause to be kept, a true and complete record of the proceedings of those meetings (b) Give, or cause to be given, any required notice of meetings of the .har.ehol~er' alld the ooa<<! of dir..ctor,,; (c) Keep in safe custody the seal of the Corporation, if the Corporation obtains one, and affix the same to any instrument requiring it; 6 (d) Certify any then existing resolutions of the board and shareholders, incumbency certificates, officer signatures, the By-Laws, or similar documents whenever the Secretary's certification thereof is required; (e) Attest to the signature of the President & CEO, or any other executive officer of the Corporation, whenever such attestation is required; and (f) Perform any and all other duties prescribed by the board or by the President & CEO. 3.7. Other Officers. The board may also appoint one or more Vice Presidents, Assistant Treasurers, and Assistant Secretaries. During a ny absence 0 r disability, a V ice President may perform all acts that could have been performed by the President & CEO, an Assistant Treasurer may perform all acts that could have been performed by the Treasurer & CFO, and an Assistant Secretary may perform all acts that could have been performed by the Secretary. 3.8. Transfer of Authority. In the case of the absence of the required officer of the Corporation (i) the board of directors may transfer the powers or duties of that officer to any other officer or to any director or employee of the Corporation, and (ii) the President & CEO may appoint an Assistant Secretary without any need for board approval. The appointment of any such Assistant Secretary shall automatically terminate when the Secretary elected by the board returns from his or her absence. 3.9. Delegatiou by Officers. An officer shall have the power to assign or delegate any or all of his or her duties or powers to any other person, unless a majority of the board vetoes that delegation by an affirmative vote. ARTICLE IV Shareholders 4.1. Place of Meetings. Meetings of the shareholders of the Corporation shall be held at the principal executive office of the Corporation. The board of directors, however, may in its discretion, authorize said meeting be held in such other place as it may determine, provided the place at which the meeting is to be held is stated clearly in the notice and call of the meeting. 4.2. Annual Meeting. The Corporation shall hold an annual meeting of its shareholders. These meetings shall be held on the first business day which occurs in the fourth month following the close of the Corporation's fiscal year. At each annual meeting, the shareholders shall (i) elect directors to the extent reqlliTf':n and (11) r.om:ic1M' J:lny nthP.T hm;:;np!I;.r;;: thM m~y prnpf"'rly hP hTnng1'tt before the meeting 4.3. Special Meetings. Any special meeting of the shareholders of the Corporation shall be subject to the provisions set forth below. . 7 4.3.1. Called bv Officers or Directors. A special meeting of the shareholders may be called for any purpose, at any time, by (i) the President & CEO, (ii) the board of directors, or (iii) any two members of the board of directors. 4,3.2. Called bv Shareholders. Anyone or more shareholders holding at least 10% of the voting power of the Corporation's shares may call a special meeting of the shareholders by delivering a request therefore in writing by registered mail or by personal service to the President & CEO, any Vice President, or to the Secretary of the Corporation. Within thirty (30) days after receipt of the demand by one of those officers, the board shall cause a special meeting of shareholders to be called and held on notice no later than ninety (90) days after receipt of the demand, all at the expense of the Corporation. Any such meeting called by the shareholders must be held in the county where the Corporation's principal executive office is located. 4.3.3. Business of Soecial Meetinl!. The business of any special meeting of shareholders shall be confmed to the purpose stated in the notice thereof (unless all of the shareholders entitled to notice have waived that notice pursuant to subsection 4.4.4 below). 4.4 Notice of Meetings. Any meeting of the shareholders, whether annual or special, shall be subj ect to the notice requirements set forth below. 4.4.1. Persons Entitled to Notice. Written notice of all meetings of shareholders shall be given to every holder of voting shares whose name appears on the record books of the Corporation. However, no notice is required if the meeting is an adjourned meeting and the date, time, and place of the meeting were announced at the time of adjournment. 4.4.2. Time of Notice. . Notice of any meeting of the shareholders shall be given by either mail or personal service. Notice by personal service shall be given at least five (5) days before the date of the meeting, and notice by mail shall be. given by depositing such notice in the mail at least seven (7) days before the date of the meeting. Notice, whether by mail or personal service, shall not be given more than sixty (60) days before the date of the meeting. 4.4.3. Contents of Notice. The notice shall contain the date, time, and place of the meeting. 10 the case of a special meeting, the notice shall also contain a statement of the purposes of the meeting. The notice may contain any other information deemed necessary or desirable by the board or by any other person or persons calling the meeting. 4.4.4. Waiver of Notice. A shareholder may waive notice of a meeting of shareholders. A waiver of notice by a shareholder entitled to notice is effective whether given before, at, or after the meeting, Mil '~hcther given in ..'tiling or 0I'll11y. 4.4.5. Waiver bv Attendance. Attendance by a shareholder at a meeting is a waiver of notice of that meeting, unless the shareholder (i) objects at the begimring of the meeting to the transaction of business because the meeting is not lawfully called or convened; or (ii) obj ects before a vote on 8 an item of business because lbe item may not lawfully be considered at tbat meeting and the objecting shareholder does not participate in the consideration of lbe item at that meeting. 4.5. Quorum. The presence, in person or by proxy, of the holders of a majority of the shares entitled to vote at the meeting shall constitute a quorum for lbe transaction of business. However, once a quorum is constituted at a meeting, the wilbdrawal of shareholders to a number less lban a majority of lbe shares entitled to vote at a meeting shall not effect lbe ability of lbe remaining shareholders to transact business ofthe Corporation. 4.6. Voting. Any action by the shareholders requires the affirmative vote of lbe holders of a majority of the voting power of lbe shares present and entitled to vote (except where lbe Articles of Incorporation or any applicable law specifies a larger or smaller percentage). 4.7. Action Without a Meeting. Any action required to be taken at a meeting of lbe shareholders of lbe Corporation, or any action tbat may be taken at a meeting of lbe shareholders, may be taken without a meeting if a consent in writing setting fortb the action so taken shall be signed by all of the shareholders entitled to vote with respect to the subject matter lbereof. This consent shall have lbe same effect as a unanimous vote of shareholders and may be stated as such in any articles or documents filed wilb the Secretary of State. The written action is effective when it has been signed by all of lbe shareholders, unless a different effective time is provided in lbe written action. 4.8. Shareholder Management. The holders of lbe voting shares of the Corporation may, by unanimous affirmative vote, take any action that lbe board is permitted or required to take. I n this event, the directors shall have no liability for any such act, and lbe shareholders alone will assume tbat liability (collectively and individually). ARTICLE V Shares of Stock 5.1. Issuance of Shares. The board of directors is aulborized and directed to issue shares of the . Corporation, to lbe full amount authorized by lbe Articles of Incorporation, in such amounts and at such times as may be determined by the board of directors and as may be permitted by law. 5.2. Consideration for Shares. The consideration for lbe issuance of lbe Corporation's shares may be paid in any lawful consideration. Shares shall be nonassessable when the agreed consideration has been fully paid, delivered, or rendered to the Corporation. Consideration in the form of a promissory note, a check, or a written agreement to transfer property or render services to the Corporation in lbe future is fully paill ',:hon tho note, cho.l~ or written agreement is lIeli>:..ed te the Cml'aratian. 5.3. Certificates Representing Shares. Each holder of capital stock of the Corporation shall be entitled to a certificate signed by lbe President & CEO and lbe Secretary of lbe Corporation, and sealed wilb lbe seal of the Corporation if one has been obtained, which contains on its face: 9 (a) The name of the Corporation; (b) A statement that the Corporation is incorporated under the laws of the State of Minnesota; (c) The name ofthe person to whom the certificate is issued; and (d) The number and class of shares, and the designation of the series, if any, that the certificate represents. In addition, on either the front or back of each certificate, there should be a statement or reference to (i) any applicable limitations described in Section 302A.417, subdivision 2, of the Minnesota Statutes; (ii) any restriction on transfer described in Section 302A.429 of the Minnesota Statutes; and (iii) any shareholder control agreement described in Section 302A.457 of the Minnesota Statutes. 5.4. Fractional Shares. The Corporation may issue fractions of a share originalIy or upon transfer. If the Corporation does not issue fractions of a share, then in connection with an original issuance of shares, it shall: (a) Arrange for the disposition of fractional interests by those entitled to them; (b) Pay in money the fair value of fractions of a share as of the time when persons entitled to receive the fractions are determined; or (c) Issue scrip or warrants in registered or bearer form that entitle the holder to receive a certificate for a full share upon the surrender of the scrip or warrants aggregating a full share. The Corporation shalI not pay money for fractional shares if that action would result in the cancellation of more than 20% of the outstanding shares of a class. A determination by the board of the fair value of fractions of a share is conclusive in the absence of fraud. A certificate or a transaction statement for a fractional share does, but scrip or warrants do not unless they provide otherwise, entitle the shareholder to exercise voting rights or to receive distributions. The board may cause scrip or warrants to be issued subject to (i) the condition that they become void if not exchanged for full shares before a specified date, (ii) the condition that the shares for which scrip or warrants are exchangeable may be sold by the Corporation and the proceeds distributed to the holder of the scrip or warrants, or (iii) any other condition or set of conditions the board may impose. 5.5. Lost. Stolen. or Destroyed Certificates. The CoqlOration shall issue a new stock certificate in the place of any certificate therefore issued where the holder of record of the certificate: (a) Makes proof in affidavit form that it has been lost, destroyed, or wrongfully taken; 10 (b) Requests the issuance of a new certificate (but only if it is before the Corporation has notice that the certificate has been acquired by a purchaser for value in good faith and without notice of any adverse claim); (c) Gives a bond required by the board to indemnifY the Corporation against any claim that may be made on account of the alleged loss, destruction, or theft ofthe certificates; and (d) Satisfies any and all other reasonable requirements imposed by the Corporation. When a certificate has apparently been lost, destroyed, or wrongfully taken, and the holder of record fails to notifY the Corporation within a reasonable time after the holder has notice of it, and the Corporation registers a transfer of the shares represented by this Corporation before receiving such notification, then the holder of record is precluded from making any claim against the Corporation for the transfer or for a new certificate. 5.6. Fixing Record Date of Share Ownership. The board may fix a date, but not more than sixty (60) days before the date of a meeting of shareholders, as the date for the determination of the holders of shares entitled to notice of and entitled to vote at the meeting. When a date is so fixed, only shareholders on that date are entitled to notice of and permitted to vote at that meeting of shareholders. ARTICLE VI Loans and Indemnification 6.1. Loans and Guaranties. The Corporation may (i) lend money to any person, (ii) guarantee an obligation of any person, (iii) become a surety for any person, or (iv) otherwise financially assist any person. However, the Corporation may do so only ifboth of the following requirements are met. First, the transaction must be approved by the affirmative vote of a majority of the board. Second, the transaction must satisfY at least one of the following: (a) It is in the usual and regular course of business of the Corporation; (b) It is with, or for the henefit of, an organization in which the Corporation has a financial interest, a business relationship, or the power to make donations; ((") It 11;: 'UTith, or fnr thf'! hpnptit of, ~-nynffi("f'I1",';1TPl':tnr, nrp.mpll\y~p.nfthp. Corporation (or its subsidiary) and, in thej udgment of the board, it may reasonably be expected to benefit the Corporation; (d) It is approved by the holders of at least two-thirds of all voting shares owned by disinterested persons; or 11 (e) It is approved by the holders of all outstanding voting shares and non-voting shares. 6.2. Indemnification. The Corporation shall indenmify and reimburse its officers and directors whenever such indenmification or reimbursement is permitted by Section 302A.52l of the Minnesota Statutes, as amended. The Corporation mav reimburse or indenmify any other person for whom indenmification or reimbursement is permitted under Section 302A.52l of the Minnesota Statutes, as amended. This provision cannot be amended or deleted retroactively, or after an event has occurred, so as to deprive any present or former officer or director of indenmification or reimbursement. 63. Insurance. The Corporation may purchase and maintain insurance on behalf of any person for acts which may potentially leave the Corporation liable for reimbursement or indemnification pursuant to Section 6.2 above. ARTICLE VII Corporate Books and Records 7.1. Required Books and Records. The Corporation shall maintain at its principal executive office, and such place or places as the board of directors may determine, originals or copies of the following books and records: (a) A share register listing the names and addresses of the shareholders, the number and classes of shares held by each shareholder, and the dates on which the certificates were issued; (b) Records of all proceedings of shareholders and directors for the last three years; (c) Its current Articles and By-Laws; (d) Reports to shareholders within the last three years; (e) A statement of the names and usual business addresses of all its directors and principal officers; (I) Financial statements required by Section 7.02 below; (g) Voting trust agreements; and (b) Shareholder control agreements. 7.2. Financial Statements. The Corporation shall keep appropriate and complete financial statements. 12 7.2.1. Annual Statements. The Corporation shall keep annual financial statements, including at least a balance sheet as of the end of each fiscal year and a statement of income for the fiscal year. 7.2.2. Other Statements. The Corporation shall also keep financial statements for the most recent interim period, if any, that were prepared in the course of operation for distribution to either (i) the shareholders, or (ii) a government agency as a matter of public record. 7.2.3. Accountinl! Methods. The statements shall be prepared on the basis of accounting methods reasonable in the circumstances (e.g. GAAP need not be applied while the Corporation is small). The statements may be consolidated statements of the Corporation and one or more of its subsidiaries. 7.2.4. Certification. In the case of statements audited by a public accountant. each statement shall be accompanied by a report setting forlb the opinion of the accountant on the statements. In other cases, each copy shall be accompanied by a statement of the chief financial officer (i) stating the reasonable belief of the person that the financial statements were prepared in accordance with accounting methods reasonable in the circumstances, (H) describing the basis of presentation, and (Hi) describing any respects in which the financial statements were not prepared on a basis consistent with those prepared for the previous year. 7.3. Inspection. A shareholder, beneficial owner, or a holder of a voting trust certificate has an absolute right, upon written demand, to examine and copy, in person or by a legal representative, at any reasonable time (i) all of the books and records set forlb in Section 7.1 above; (ii) the financial statements required by Section 7.2 above; and (iii) any other corporate records if that person demonstrates a purpose reasonably related to the person's interest as a shareholder, beneficial owner, or holder of a voting trust certificate of the Corporation. 7.4. Copies. If the requesting party has a right to inspect the corporate books and records pursuant to . Section 7.3 above, then all copies shall be furnished at the expense of the Corporation. In all other cases, the Corporation may charge the requesting party a reasonable fee to cover the expenses of providing the copies. ARTICLE VIII Dividends and Distributions R: 1 ni~trihntinn TIpfinM A "diitrihl1tinn" ind'ldes a dividend, but i~ br.Qjlger nDi~tributioo" means a direct or indirect transfer of money or other property, other than its own shares, with or without consideration, or an incurrence or issuance of indebtedness, by a corporation to any of its shareholders in respect of its shares. A distribution may be in the form of a dividend or a distribution in liquidation, or as consideration for the purchase, redemption, or other acquisition of its shares, or otherwise. 13 8.2. When Payable. Distributions of the Corporation may be declared by the affirmative vote of the board at any regular or special meeting. The board may authorize a distribution only if. after making the distribution, the Corporation will be able top ay a II 0 fits debts i n the 0 rdinary course 0 f business. Accounting periods are irrelevant; only the financial condition of the Corporation at a given moment shall control. The determination may be based on any reasonable method of accounting or valuation. 8.3. Reserve Fund. Prior to the declaration or payment of any dividends, the board may set aside such sum or sums as the directors, from time to time in their absolute discretion, think proper as a reserve fund to (i) meet contingencies, (ii) equalize distributions, (iii) repair or maintain any property of the Corporation, or (iv) for such other purpose that the directors deem to be in the best interest of the Corporation. ARTICLE IX Amendments of Articles 9.1. Before S hares a re I ssued. If shares of the Corporation have not yet been issued, then either the incorporator or the board may amend the Articles of Incorporation. In such an event, the Corporation need not refile, but must only comply with subsections 9.2.5 and 9.2.6 of these By-Laws. 9.2. After S hares a re I ssued. The Articles of Incorporation may be amended, once shares have been issued, only by following the procedure below: 9.2.1. Resolution to Amend. A resolution setting forth amendments to the Articles may be submitted by either (i) the board of directors, or (ii) any shareholder or shareholders holding at least 3% of all voting shares. 9.2.2. Submission to Shareholders. The resolution shall thereafter be submitted to a vote of the shareholders at the next regular or special meeting for which notice can still be timely given but has not yet been given. Notice must be given as provided in Section 4.4 of these By-Laws. The notice shall set forth the substance of the proposed amendment. 9.2.3. Shareholder ADDroval. The proposed amendment is adopted when approved by the affirmative vote of the holders ofa majority of the voting power of the shares present. However, if the amendment proposes an amendment to require a larger majority vote than that currently in existence, then that amendment must receive the affirmative vote of that same larger majority in order to be approved. 9.2.4. Cla~'Ii: Vntino Thp. hnlnPT"- of ~n nntlOlhlncling f"'llllQl;: or 'j!eri{"~ of Qh!'lTPQ lO:h!'ll1 hp pntitl("d to "ok as a class or series on any proposed amendment (i) which adversely affects their rights as shareholders according to Section 302A.137 of the Minnesota Statutes, or (ii) whenever the terms of those shares permit class voting. 14 9.2.5. Documentation of Amendments. The approved amendments shall be documented by following the procedure set forth in Section 302A.139 of the Minnesota Statutes. 9.2.6. Effective Date. Articles of Amendment shall be filed with the Secretary of State. The Articles of Amendment are effective when so filed. However, the Articles of Amendment may state a later effective date, so long as that effective date is within 30 days ofthe filing date. 9.3. Dissenting Shareholders. If an amendment of the Articles adversely affects the rights and preferences of the shares of a dissenting shareholder [as defined in Section 302A.471 subd. I(a), of the Minnesota Statutes], then that shareholder shall have the right to obtain from the Corporation the fair value of his or her shares. 15 ARTICLE X Amendment of By-Laws 10.1. By the Board. The board shall have power to amend or repeal the By-Laws (except to the extent limited by subsections 10.1.1 and 10.1.2 below). 10.1.1. Prohibited Amendments. Unless otherwise provided in t he Articles 0 fI ncorporation, i f initial By-Laws have been adopted, then the board cannot adopt, amend, or repeal provisions of the By-Laws that (i) fix a quorum for shareholder meetings; (ii) prescribe procedures to remove directors; (iii) prescribe procedures to fill board vacancies; (iv) decrease the number of directors; or (v) fix the qualifications, terms of office, or classification of directors. 10.1,2, Shareholder Veto. The shareholders shall always have the power, by utilizing Section 10.2 of these By-Laws, to override actions of the directors in adopting, amending, or repealing By- Laws. Any action so taken by the shareholders may not be changed except by the shareholders. 10.2. By the Shareholders, Any shareholder or shareholders holding at least three percent (3%) of the voting shares of the Corporation may propose a resolution to amend or repeal the By-Laws. If a shareholder or shareholders makes such a proposal, then the resolution shall be submitted to the shareholders and voted upon as follows: 10.2.1. Submission to Shareholders. The resolution shall thereafter be submitted to a vote of the shareholders at the next regular or special meeting for which notice can still be timely given but has riot yet been given. Notice must be given as provided in Section 4.4 of these By-Laws. The notice shall set forth the substance of the proposed amendment. 10.2.2. Shareholder Approval. The proposed amendment is adopted when approved by the affirmative vote of the holders of a majority of the voting powers of the shares present. However, if the amendment proposes an amendment to require a larger majority vote than that currently in existence, then that amendment must receive the affirmative vote of that same larger majority in order to be approved. 10.2.3. Class Votin!!. The holders of an outstanding class or series of shares shall be entitled to vote as a class or series on any proposed amendment whenever the terms of those shares permit class voting. 10.3. Dissenting Shareholders. Dissenting shareholders shall not be entitled to payment for the fair value of their shares as a result of any amendment to the By-Laws pursuant to this Article. 16 ARTICLE XI Required Reports 11.1. Income Tax Filings. The Corporation shall file any return required by Section 290.37 of the Minnesota Statutes. However, if the Corporation is a small business corporation, then it shall file any return required by Section 290.974 ofthe Minnesota Statutes. 11.2. Annual Report. Each year the Corporation shall file the Minnesota Corporate Registration required by Section 302A.82I of the Minnesota Statutes. 11.2.1. Place of Filiul!. The registration shall be filed with either (i) the Commissioner of Revenue along with the return described in Section 11.1 above, if any, or along with an affidavit that no such return need be filed; or (ii) the Secretary of State. 11.2.2. Contents. The registration that is filed by the Corporation shall contain all of the following information: (a) The name of the Corporation; (b) The address of its principal executive office; (c) The address of its registered office; (d) The state of incorporation; (e) The former name and address of the Corporation or its registered office, if changed since the Corporation filed its previous return; (I) The name of its registered agent, if any; and (g) The name and business address of the officer or other person exercising the principal functions of the chief executive officer of the Corporation. 11.2.3. Penaltv. The failure to file once will result in loss of good standing and a $25 fine. The failure to file in two consecutive years may lead to dissolution of the Corporation. 11.3. Change of Registered Offiee. The Corporation shall change its registered office in all cases where the registered 0 ffice presently on file is no longer utilized by the Corporation. Every change of registered office shall be filed with the office of the Minnesota Secretary of State 17 APPENDIX C Certificate of Existence ( I ~! - - -. APPENDIX C Organizational Chart ( ZOHAR HEALTHCARE, LLC 20-56323R5 I II 41-]flS4069 INTREPID U.S.A. INC 41-1946901 INTREPID Cor...WANIES, INC. 41-1467~96 (homccarcorfic<,;~) II 41-19ti4r.77 II 75-3020142 41.2016751 41-llj46ljl~ 41-20D9R2 INTREPID ICM, lNC INTREPID INTREPID INTREPID Fe INTREPIO OF I Of IDAHO. INC. AMERICA,INC. AFFILIATES, ACQUISITION GOLDEN V ALLEY, (Iic<,;nscc) (supplemental I;-.JC. CORPORA TlON lNC. . Intrepid "fEdina. Inc. (41-1~217Xl) slaftlng) (frdnchiset:s) . hmcpid of Indiana. Inc. (41-1946906) . lntrcpidoflu"i".Inc.(4t-1840813)__(HCo?p) I . lnlrcpidof'vlillneS01J.lnc.(41-16871.17) . Imn:pidofc.l;""uri.l"o_l41.1864442) " IntrepidnfMllTlI"n". Inc. (71-0876438) ~ Intrepid ofNebra,ka.lnc.(41-]<)469D7) . In!repid AmcrkaColorado. Inc. (4i.t946903) . Inlrcpid ofNcwJc"ey, Inc.(41.1'M6'110) . InlrepidAmcrica-F1orida,lllC.(41_lr)46900) . F-c"r Alab","a.lnc, (20-00g6J6U) . 1ntrel'idofNcwMcxico,lnc.(41_I'I46'J11) . Inlrel'idAmcric""(iC<.l~ia,lTlc.(41_1'l46'105) . F,c'ofArizona.lnc.(20-0086J46) . Inlr~pid of New York. In.;:. (41-19477S6) - fNl"C"rp) . Inlrcpid Amcrica-Indiana. Inc. (41-2016{NJ) . F,c.(.rArbn"a".lnc,(20_()()%74~) . Inlrepid c'f 1\01111 Camlina, Inc. (56-1 864549) - INC C~rpJ . InlrepidAl11erica-~il1ne"otJ.lnc,(41-2017011) . F,C.()fFIMi,kfnc.(20..()0~6J'JJ . 111IropidDfNn'T11 O"bw. Inc. (41-16871J6) . InlropidAmerica_Mi""""i. Inc. (41-2020267) . F.C.ofGeorgia.lnc (20.00~6316) . Illlrcpidc>fOhio.lnc.(41_i946913) . IlIlrcpid Am~Tic,,-"ebrasb. ln~. (41-2031042) . r,c, "flndinnJ. lnc, (20-()O~62HI \ Il,lndle Wilh Care SCr\icc', lnc, (,4-1753117) - (OH C~rp) . lnlrepid;\merica.NonhCarolinJ.lnc.161-1424ISS) . F,C "rK""trrcky, Inc. (20-006J168) . Handle ,>\'ilh Care Mcdicare Agency, Inc, (34-1673611) _ (OH CMp) . lntrepidAmericn_Not1hcm Flllrida. lnc,(41.1'I62916) . F.C'.llfMi<<i<<ippi.lnc(20.0086255) . MOrr1'()!l IlmncCan::.lnc, (~4-1,~I()('O~) - (OH Corp) . InTrcpid Amcrica-Ohio. Inc. (45-0469529) . f.C.ofMi"omi.lnc.(20_0()(,3750\ . !\,mhCoO>l Hcallh Ca,e Group, Inc. (J4"1479651)-(OHCorp) . lntrepidAmerica.On::gc>n,lnc.(41-1946914) . F,C.()fPentl,ylval\in.lnc.C().[)O~('"41) Nt: HHA, lnc, 04-1376662)-- (OHCorp) . IntrcpidAmcrica-Texa"lnc.pS_2990246} . F,C."rS"lLlhCamlina.ln~(20-()()8621;,) NnrthCoa;llleallh Care Nursing Service" Inc (34-147%50)- (OR Corp) . 1"trepidAmcric"-W,,,hin!,'l()!).ln~.(45-0469401\ . rc.(lITennesse..:.lnc.(lO-OOM1'!6) . NonhCoRsl Hcalth Care Managcmenl Se,,'i~e'. Inc. (34-1797543) - (OH Corp) . F,Cnt--]'"x".1r\c.(2().()()~;,1()8) . Imrepid ofOklahomn, In"(41-2022S07) . F,C.llfVirginia. In~. (20-0086079) . Amenc.1re C",r,plete Car~, In.;:, (5r)-JJ335H~) - (OK Corp) . F.c.ofW~stVirginia.lnc.(20_1I11('37(J9) . AmcricJr<:of SOUlhem Oklahoma.lnc, (73-16037021- (OK Corp) . Imrol'idnfRhndeblan,I.Jnc.(41-1946899) . Intrepid llrRuchcstcr,ltlc, (41.18759l!6) ~ Intrepid of Southern Minnesnla, Inc. (41-1835%4) . IntrcpidofStC[oud,lnc.HI_18704!J) . lntr~l'id nJ"Tcnnc<<ce. !n~.{20.0086U9) ~ lnlrcpidorTexas.lnc.(41-1946915) . Inlr.pid Hnme Ik,llh CHrc, Inc. (75-280mO~). (rX Corp) . Illlrq,i,1 orlhe Memlpkx. Ine, (75-2466172) _ (TX Corp) . Intrcpid orS3LtAnt"nio, Inc. (74-2705698)-(rXC"rp) . Intrepid nl"S"ull, T CX"', Inc. (7S-2855905) _ (TX Corp) . Inh1,irinl"EI Paso. hlC. (75-2M0683)-(TXCorp) . Int'cpid ofAuSlill'fCXas, Inc. (7S-2922591)-(TXCorp) . Intrepid OfSoulhen.t Te.a,. IllC, (76.0:193658) - (TX Corp) . lntrr::pi,lnrAmarillo.1nc.(75_2907378)_(lXCorp) . Intrepid nrWestTe,xas. lnc, (75-241il535)_rrXC"rp) . Intrepid ofHouSI"" Texa'. Inc, (76-0387856) - (TXCQfP) Intrepid "1"1\',,rlhca;1 Texa,. Inc. (7S.2855900)- (lX C~rp) IntrcpidofS(luthemColoradn, Ino. (75-2855901}-rrXCorp) . lntrcpidofSouthea,t Lnui,innll, In~, (i2-1235949) -(LA C"rp) . lntrcpid"I"I."ui,i'IIl". !nc.(72-1236171). (LA Corp) . Intrepid"l"lhcTwinCilics.lnc. (2~-)8597661 . lnlrcpid of\'ir~inia.lnc. (41-1946916) . hllrepid<,rWnshin!,>ton.!nc.(41_1946'l17) . InlrcpidnrWi;e,)",in.lnc.Hl.1854511) ~ lnlrepid USA-Il.S.1nc.(lO-O(lI4071) . lntrcpidUSA-PCPO,lllc.(20_0614nX6) APPENDIX C Company History HISTORY A Founding and Acquisition History Founded by Todd Garamella in 1994, Intrepid has grown pnmarily through acquisitions of home nursing and supplemental staffing agencies. Beginning in 1998, the Company commenced expansion beyond the Midwest and began focusing on larger acquisitions. The acquisition strategy was focused on acquiring undenmanaged or underperforming agencies, improving the financial performance and integrating them into the regional and corporate infrastructure. ($ in milfions) iiIIIIIIJIIIII;III[iilf,llllfJli'lIIIJ'lrlllflllllf,$11ffi~==;%A%#M\tti.:Mwi.?%fd 1994 1995 $0.6 0.8 0.5 0.4 1.2 1.0 3.5 1.5 5.5 24.0 1996 1997 K.L. Healthcare Central Staffing Services New Horizons Home Care TheraPedics and Firstat of Sl Louis Virtual Home Care Central Minnesota Care Centers Shamrock In-Home Nursing Care Nursing SelVices of Iowa HealthMate acquisitions (2) Western Medical Services, tnc (Owned) 1998 1999 2001 Western Medical Services. Inc. (Franchises) Dependable Home Care Becklund Home Health Care Oklahoma acquisitions [3] Allina Home and Community Services Ohio acquisitions (41 Handle with Care acquisitions (5) Western Medical Services - Spokane, WA Westmant Home Care VNA of North Carolina J.J.E.O. Home Care Medshares, Inc.lSoleus Healthcare 20.0 1.2 24.0 7.5 5.5 5.0 1.3 0.2 2.5 0.5 1.0 76.0 2002 20031') Interlink Heal!hcare Services 16.0 MN MN MN MO MN MN MN IA NC,OH.IN CO, FL, GA.IN, MO, NE, NJ, NM, NY, OH. OR, TX. VA, WA FL, IN, KY, Ml, MT, NJ, OH, WA RI MN OK MN OH OH WA MT NC NY AL, AR, AZ, FL. GA, IN, KY, MO, MS. PA. SC, TN. TX. VA, 'MJ CO, LA, TX OJ Ap{Xoximale net revenues allime of acquisi~'on (2) Includes HsaJrhMale, Inc. and HeallhMale Indiana, fnc. acquisiUons. (3) Includes Americare Complete Care, Americare of Southern Oklahoma and Cardinal Home Care acqwsilions {4} Includes NorthCoasf Home Care and Morrison Home Care acquisiYons (5) Includes Handle With Care Medicare Agency and Handle Wifh Care Services acquisitions (6) As a resulf of/he Medshares and Interlink acquismons, the Company had 13 overlapping offices in six markefs The Company consolidated 12 of these offices in 2003 prior to the bankruptcy filing. . Beginning in 1999, Intrepid developed a relationship with lender DVI, Inc. DVI funded many of the Company's acquisitions, including its four largest acquisitions listed below. Western Medical Services Becklund Home Health Care Medshares, Inc. I Soleus Healthc.re Interlink Home Health Care In August 1999, the Company acquired the assets of West em Medical Services, which was headquartered in : Walnut Creek, California. This acquisition added 35 offices in 16 states and approximately $44 million of net revenues. In August 2001, lIle Company acquired Becklund Home Heallll Care located in Golden Valley, Minnesota. Becktund operated four offices in the Minneapolis/St. Paut metropolitan market and had approximately $24.0 million in annual net revenues. On June 30. 2003. the Company completed the acquisition ot the assets at Medshares. Inc. and its affiliated entities. Headquartered in Memphis, Tennessee, Medshares was founded in 1984 and filed for bankruptcy in July 1998. At its peak, Medshares had approximately 14,000 employees in 29 states. Medshares acquired the majority of its home health offices in two separate acquisitions. Medshares acquired 154 locations from Cofumbia/l-lCA Heafthcare Corp. in October 1998 and 251/ocatians from Integrated Health Services in February 1999. Medshares had 161 affiliated home health agencies when it filed for bankruptcy protection. Intrepid acquired approximately 80 offices in 15 states INith approximately $76.0 million of revenues. In June 2003, lIle Company received bankruptcy court approval to acquire lIle stack of Interlink Home Heallll Care, Inc., which was headquartered in Dallas, Texas. Interlink was acquired in May 2002 by the Phoenix Group Corp. At the time of the Phoenix Group acquisition, Interlink operated 30 home nursing offices in Texas, Colorado and Louisiane. The Phoenix Group filed tor Chapter 11 bankruptcy in August 2002. Intrepid acquired an interest in a subordinated foan of fnterUnK. With bankruptcy court approval, lntrapid asserted its right to operate InterUnk due to a default in the subordinated loan agreement prior to the acquisition in June 2003. Through this acquisition, Intrepid acquired 20 new offices and approximately $16.0 million in annual nel revenues. APPENDIX C Authorization to Conduct Bnsiness in Georgia STATE OF GEORGIA Secretary of State Corporations Division 315 West Tower #2 Martin Luther King, Jr. Dr. Atlanta, Georgia 30334-1530 CERTIFICATE OF EXISTENCE I, Cathy Cox, Secretary of State and the Corporations Commissioner ofthe state of Georgia, hereby certify under the seal of my office that F.e. OF GEORGIA, INC. Foreign Profit Corporation was formed or was authorized to transact business on 08/04/2003 in Georgia. Said entity is in compliance with the applicable filing and annual registration provisions of Title 14 of the Official Code of Georgia Annotated and has not filed articles of dissolution, certificate of cancellation or any other similar document with the office of the Secretary of State. This certificate relates only to the legal existence of the above-named entity as of the date issued. It does not certifY whether or not a notice of intent to dissolve, an application for withdrawal, a statement of commencement of winding up or any other similar document has been filed or is pending with the Secretary of State. This certificate is issued pursuantto Title 14 of the Official Code of Georgia Annotated and is prima-facie evidence that said entity is in existence or is authorized to transact business in this state. WITNESS my hand and official seal ofthe City of Atlanta and the State of Georgia on 8th day of November, 2006 .~ Cathy Cox Secretary of State Certification Nmnber: 386578~ I Reference: Verify this certificate online at http://corp.sos.state.ga.us/corplsoskb/verify.asp DOMESTIC BUSINESS CORP0RATION Page 1 of 1 MINNESOTA SECRETARY OF STATE 2005 DOMESTIC CORPORATION ANNUAL . RENEWAL Minnesota Statutes Cllapter 302A1319B Must be filed by December 31 Annual Renewal Filing Date: 12/15/2005 F.G of Georgia, Inc. 6600 France Ave S # 510 Edina, MN 55435- CURRENT INFORMATION ON FILE: File# : 552362-12 State of Incorporation: MINNESOTA Entity Name: F.G of Georgia, Inc. Registered Agent! Registered Office Address: [No Name Provided] 6600 France Ave S # 510 Edina, MN 55435- IPrevious IIGnrent I Principal Executive Office Address: Principal Executive Office Address: 6600 France Avenue South, Suite 510 6600 France Avenue South, Suite 510 Edina MN 55435-1804 Edina MN 55435-1804 Name and Business Address of GE.o.: Name and Business Address of GE.O.: Todd Garamella K.James Ehlen 6600 France Avenue South, Suite 510 6600 France Avenue South, Suite 510 Edina MN 55435-1804 Edina MN 55435-1804 Contact Information: Anita Sutton 952-285-7377 Asutton@intrepidusa.com https://onIine.sos.state.rnn.us/abr/corp_annual )iling.asp?spage=af-i&page ~view&filingnu... 12/15/2005 sosform " Page I of 2 ""~I!' :J.........-,.,.".-..-') l:>~-:;";i. "',., '~~'>' ~-J'......;r 1,;-,):;,/ . ..~<:.;:~:? STATE OF GEORGIA 2006 ANNUAL REGISTRATION CORPORATIONS DIVISION Office of Secretary of State (404) 656-2817 ENRICO M ROBINSON Director CA1HY COX Secretary of Slate Thank you for registering online. Your Tracking Number Is: 20060125155421588 Please PRINT this receipt for your records. ENTITY-CONTROL-NUMBER: 0342940 TOTAL a-IARGED: $60.00 ENTITY INFORMATION ENTITY-NAME: F,e. OF GEORGIA, INe. PRINapAL-ADDRESS: #510,6600 FRANCE AVE. SOUTH PRINaPAL-aTY: EDINA PRINaPAL-STATE: MN PRINaPAL-ZIP: 55435 REGAGENf-NAME: CORPORATION PROCESS COMPANY REGAGENf-ADDRESS: 180 CHEROKEE STREET, N.E. REGAGENf-aTY: MARIE TT A REGAGENf-STATE: GA REGAGENf-ZIP: 30060 REGAGENf-CDUNTY: COBB CEO INFORMATION NAME: K. JAMES EHLEN, MD ADDRESS: #510,6600 FRANCE AVE. SOUTH aTY: EDINA STATE: MN ZIP CDDE: 55435 CFO INFORMATION NAME: GREG VON ARX ADDRESS: # 510,6600 FRANCE AVE. SOUTH aTY: EDINA STATE: MN httpsj/www.ganet.org/sosonline/renew.cgi 1/25/2006 sos{orm Page 2 of 2 ZIP roDE: 55435 SEe INFORMATION NAME: KJAMESEHLEN,MD ADDRESS: # 510,6600 FRANCE AVE. SOUTH aTY: EDINA STATE: MN ZIP roDE: 55435 SUBMITTED BY: Greg Von Arx on 01125/2006 Please click here to renew another entity. This credit card transaction was processed by the GeorgiaNet Authority. Please print a copy of this for your records. The description on your credit card statement will be: GA Sec of State Corporation Services https:// www.~anet.org/sosonline/renew.cgi 1/25/2006 !: APPENDIX D Site Verification AMERICUS VILLAGE SHOPPING CENTER G. EARL SNIDER, OWNER 148 MEADOW DRIVE AMERICUS GA 31709 229-942-2365 October 31, 2006 Becky Daniel Intrepid USA Healthcare Services 1901 Palmyra Road Albany, GA 31701 Dear Ms. Daniel, My name is Earl Snider and I am the owner of Americus Village Shopping Center in Americus GA. I would like to offer for rent an office that is approximately 1125 square feet. The address is 1610-D East Forsyth Street, Americus GA 31709. It will be available 11-1-06 and the rent is $750 a month. I ask for a one year lease and will include the option to renew for future years. If you have any other questions, please call me at 229-942-2365. I look forward to talking with you. Sincerely, ~ Earl Snider APPENDIX E Supplemental Need Documentation None ProvIded APPENDIX F SupplementalExistlng Alternatives Documentation None Provided APPENDIX G Ii 1'1 II Ii 'I II I Ii 'I I' ,I (! I , Ii Ii 11 I I! " iI II I I !, II 'I !I II Ii I' II Ii i II II II , iI Funding Commitment Letter ( ~, intrepid~'" HE A l T H CA IE \ E R V I (E \ October 27, 2006 6600 France Avenue South Suite 510 Edino, MN 55435 Phone 952.285.7300 Fax 952.920.3316 www.inlrepidusa.com Re: Proof of Necessary Funding To Whom It May Concern: This letter is written to confirm that F.C. of Georgia, Inc., d/b/a Intrepid USA Healthcare Services currently has the necessary funds to complete the CON process. F.e. of Georgia, Inc. is a subsidiary of Intrepid U. S. A, Inc., which in turn is owned by private funds, managed by Patriarch Partners, LLC ("Patriarch"). Patriarch currently manages . funds representing an aggregate $5 billion in assets under management. Intrepid U.S.A currently has on hand the necessary funds to complet~ the CON process. If you have any further questions, please do not hesitate to let me know. "Thank you for your attention to this matter. Sincerely, ~ !/AO eg~ Von Arx Chief Financial Officer I , . We find a way / , ii I' I I I, ji I: II 'I 1 II I, Ii II Ii II II I I APPENDIX G Consolidated Financials I, Ii II II I' j! Ii I' II ,I Ii II II Ii 'I I, II " Ii II I, " II ], I' il II I:i 'I I, Ii II II INTREPID U.S.A., HEAL THCARE SERVICES Summary For the Ten Periods Ending October 1, 2006 Consolidated REVENUE Total Net Revenues 103,128,281 DIRECT EXPENSES Wages - Direct 37,362,973 Benefits - Direct 122,092 Franchise - Direct Insurance - Direct 2,553,083 Medical Supplies - Direct 80,040 Payroll Taxes - Direct 3,839,814 Sub Cont - Direct 4,303,985 Travel & Transportation - Direct 5,593,470 Other- Direct 2,019,534 ~----------------- Total Direct Expense 55,874,991 Gross Margin 47,253,290 OPERATING EXPENSES Wages - Operating 26,693,075 Franchise - Operating 52,995 Advertising 629,519 Benefits - Operating 2,101,510 Travel - Operating 913,325 Equipment 270,231 Insurance - Operating 346,386 Payroll Taxes - Operating 1,960,462 Telecommunications 1,778,533 Postage 241,159 Supplies 2,588,386 Medical Director Fees 100,760 Utilities 306,302 Other - Operating 3,125,519 ______.____h_____ Total Operating Expenses 41,108,162 FIXED EXPENSES Depreciation 794,442 Amortization 520,943 Interest 7,352,249 Legal/Professional 814,631 Gain/Loss on Assets (102) Other Income (Expense) (135.214) Rent 3,187,824 Licenses & Permits 64,162 Taxes - Corporate Income Tax (56,872) Taxes - Property 49,104 Taxes - Other 206,432 --.-.------------- Total Fixed Expenses 12,797,599 Total Expenses (Operating & Fixed) 53,905,761 INTREPID U.S.A, HEAL THCARE SERVICES Summary For the Ten Periods Ending October 1,2006 Operating Profit(Loss) Corporate Allocation Corporate Allocation Bad Debt Recovery Potential Bad Debt Bad Debt Expense Net Profit(Loss) before Restructuring Expenses Chief Recapitalization Department Restructuring Fees - Pre Bankruptcy Restructuring Fees - Lawyers Restructuring Fees - Advisors Restructuring Fees - DIP Loan Fees Restructuring Fees - Court Costs Restructuring Fees Restructuring Fees - Accounting Restructuring Fees - Claims Bankruptcy Claims Expense Net Profit(Loss) after Restructuring Expenses Add Back: Interest Corporate Taxes Chief Recapitalization Department Restructuring Charges Gain/Loss on Sale of Assets Depreciation Amortization Other Income Total Add Back EBITDAR Consolidated (6,652,471) (10.307,022) 10,307,022 (150.877) 373,003 (6,874,597) 97,061 99,854 253,066 386,029 714,453 203,779 27,815 193,294 41,873 53,105 (8,944,926) 7,352,249 (56,872) 97,061 1,973,268 (102) 794,442 520,943 (60,399) 10,620,590 1,675,664 ---------- ---------- INTREPID U,S.A., HEAL THCARE SERVICES Summary For the Thirteen Periods Ending December 31, 2005 REVENUE Total Net Revenues DIRECT EXPENSES Wages - Direct Benefits - Direct Insurance - Direct Medical Supplies - Direct Payroll Taxes - Direct Sub Cant - Direct Travel & Transportation - Direct Other-Direct Total Direct Expense Gross Margin OPERA T1NG EXPENSES Wages - Operating Franchise _ Operating Advertising Benefits - Operating Travel - Operating Equipment Insurance - Operating Payroll Taxes - Operating Telecommunications Postage Supplies Medical Director Fees Utilities Other - Operating Total Operating Expenses FIXED EXPENSES Depreciation Amortization Interest Legal/Professional Gain/Loss on Assets Other Income (Expense) Rent Licenses & Permits Taxes - Corporate Income Tax Taxes - Property Taxes - Other Total Fixed Expenses Total Expenses (Operating & Fixed) Consolidated 145,869,206 54,403,236 55,906 5,332,337 67,418 5,419,814 6,671,371 6,985,134 1,821,214 80,756,430 65,112,776 32,843,810 1,657,319 619,486 3,186,818 784,790 311,851 812,512 2,414,417 2,300,918 345,643 2,923,522 81,478 393,326 2,367,073 51,042,963 1,012,191 69,898 148,405 583,063 (3,271) (621,418) 4,623,277 87,604 929,201 63,328 422,388 7,314,666 58,357,629 INTREPID U.S.A, HEAL THCARE SERVICES Summary For the Thirteen Periods Ending December 31, 2005 Operating Profit(Loss) Consolidated 6,755,147 Corporate Allocation Corporate Allocation Shared Allocations Bad Debt Recovery Potential Bad Debt Bad Debt Expense (13,552,201) 13,552,201 o (59,079) 1,492,294 Net Profit(Loss) 'before Restructuring Expenses 5,321,932 Chief Recapitalization Department Restructuring Fees - Pre Bankruptcy Restructuring Fees - Lawyers Restructuring Fees - Advisors Restructuring Fees. DIP Loan Fees Restructuring Fees. Court Costs Restructuring Fees - Accounting 600,307 1,362,280 2,407,519 5,124,846 2,761,083 937,000 682,528 Net Profit(Loss) after Restructuring Expenses (8,553,631) Add Back: Interest Corporate Taxes Chief Recapitalization Department Restructuring Charges Gain/Loss on Sale of Assets Depreciation Amortization Other Income 148,405 929,201 600,307 13,275,256 (3,271) 1,012,191 69,898 (337) Total Add Back 16,031,650 EBITDAR 7,478,019 -------------- -------------- 5.13% INTREPID U.S.A, INC. GA For the Ten Periods Ending October 1, 2006 REVENUE Total Net Revenues DIRECT EXPENSES Wages- Direct Benefits - Direct Franchise - Direct Insurance - Direct Medical Supplies - Direct Payroll Taxes - Direct Sub Cont - Direct Travel & Transportation Direct Other- Direct Total Direct Expense Gross Margin OPERATING EXPENSES Wages - Operating Advertising Benefits - Operating Travel- Operating Equipment Insurance - Operating Payroll Taxes - Operating Telecommunications Postage Supplies Medical Director Fees Utilities Other - Operating T olal Operating Expenses FIXED EXPENSES Depreciation Interest Rent Licenses & Permits Taxes - Property Total Fixed Expenses Total Expenses (Operating & Fixed) Operating Profit(Loss) Corporate Allocation Potential Bad Debt Bad Debt Expense Net Profit(Loss) before Restructuring Expenses Net Profit(Loss) after Restructuring Expenses Add Back: Interest Depreciation Total Add Back EBITDAR 2006 YTD Throuah 1011/06 3,194,510 848,607 4,065 61,417 81 81,496 15,535 144,786 73,919 1,229,906 1,964,604 808,808 21,485 50,070 14,308 707 5,276 57,518 32,947 6,559 109,548 950 13,650 30,516 1,152,342 3,348 43 110,880 1,614 1,326 117,211 1,269,553 695,051 319,451 9,082 366,518 366,518 43 3,348 3,391 369,909 11.58% INTREPID U.S.A., INC. GA Fertlle Thirteen Periods Ending December 31,2005 REVENUE T 01al Net Revenues DIRECT EXPENSES Wages - Direct Benefits- Direct Franchise - Direct Insurance - Direct Payroll Taxes. Direct Travel & Transportation - Direct Other-Direct Total Direct Expense Gross Margin OPERATING EXPENSES Wages - Operating Advertising Benefits - Operating Travel- Operating Equipment Insurance - Operating Payroll Taxes - Operating Telecommunications Postage Supplies Medical Director Fees Utilities Other - Operating Total Operating Expenses FIXED EXPENSES Depreciation Interest Rent Licenses & Permits Taxes - Corporate Income Tax Taxes - Property Taxes - Other T 01al Fixed Expenses Total Expenses (Operating & Fixed) Operating Profit(Loss) Corporate Allocation Potential Bad Debt Bad Debt Expense Net Profll(Loss) before Restructuring Expenses Net Profrt(Loss) after Restructuring Expenses Add Back: Interest Corporate Taxes Depreciation Total Add Back EBITDAR 2005 YTD 4,061,129 1,222,167 246 105,425 115,313 201,685 74,891 1,719,727 2,341,402 953,679 14,518 94,742 12,141 444 7,963 68,900 51,838 8,558 118,763 7,500 14,314 15,184 1,368,544 198 34 132,679 1,572 10 3,471 o 137,964 1,506,508 834,894 402,196 21,216 411,482 411,482 34 10 198 242 411,724 10.14% I( APPENDIXG Detailed Pro Formas & Assumptions 'i Ii I II I, "I II Ii II Ii ii II Ii II II Ii I, 'i , 'I II I' Ii , II !I Intrepid Assumptions for Pro-Forma Financial Statements For The First Two Years ofOperatioDs SSDR 8 New Agency Americus, Georgia The Pro-Forma Financial Statements were prepared utilizing: Financial Data per the 12/3112005 Medicare Cost Report for the existing Intrepid Agency in Albany, Georgia. Visits distributions and Payor Source percentages were based upon the Georgia HHA Survey for 2005.Visits per Patient were based upon the Average for SDR 8 at 18.56Average Visits per Patient overall. Medicare Average Visits per patient were based upon the Average Medicare Visits per Patient for SDR 8 of21.16. Patients available were based upon the need published in the Batching Notice dated 9/14/2006. Location: The Agency will be located in Americus, Georgia. The Agency will serve Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor Counties. The new Agency's will service 75% of the projected need in Year I (2007 - 2008) and all of the projected need, 702 Patients, by Year 2 (2008 - 2009). Visit Mix by Discipline: (based OD Georgia HHA Survey 2005). Year 1 Year 2 Discipline 2007 - 2008 2008 - 2009 Skilled Nursing 46.82% 46.82% Phvsical Therapv 28.22% 28.29"10 Occupational Therapy 4.57% 4.53% Speech Theraov 1.02% 1.01% Medical Social Worker 0.92% 0.92% Home Health Aide 18.45% 18.43% Total 100.00% 100.00% Note: Variances between the pro forma assumptions and the Georgia HHA Survey 2005 is due to the distribution and rounding of the visits over a 12 month period. Visits Mix by Payor Source: (based on Georgia HHA Survey 2005). Year 1 Year 2 Pavor 2007 - 2008 2008 - 2009 Medicare 83.13% 83.13% Medicaid 5.59% 5.62% Indigent 1 2.90% 2.86% Insurance / Private Pav 8.38% 8.39% Total 2 100.00% 100.00% Note 1: Indigent is projected at 3% of Gross Charges. Indigent equals 3.32% of Net Charges in Year I and 3.36% in Year 2 Note 2: Variances between the pro forma assumptions and the Georgia HHA Survey 2005 is due to the distribution and rounding of the visits over a 12 month period. Intrepid New Agency - SSDR 8 Americus, Georgia Assumptions for the Pro-forma Financial Statements Page 2 Visits by Discipline: Year 1 Year 2 Discioline 2007 - 2008 2008 - 2009 Skilled Nursing 4,575 6,099 Physical Therany 2,758 3,685 Occunational Therapy 447 . 590 Speech Therapv 100 132 Medical Social Worker 90 120 Home Health Aide 1,802 2,401 Total 9,772 13,027 For the Expanded Agency, it is estimated that 75% (527 Patients) of the need of702 Patients will be serviced in the Year 2007 and 100 % (702 Patients) for Year 2008, The Americus Agency average visits per patient equals 18.56 visits per Patients. Medicare Visits per Patient equals 21.16. Charges: Discipline 2007 2008 Skilled Nursin. $165.00 . $169.95 Physical Theranv $185.00 $190.55 GccuP. Therapv $185.00 $190.55 Sneech Theranv $185.00 $190.55 Medical Soc. Scrv. $185.00 $190.55 Home Health Aide $ 90.00 $92.70 The Charge structure in effect, for the two-years, was uniformly applied to all Payors. Charges were increased between Year 2007 and Year 2008 periods by 3%. Actual Revenues: All Revenues (Gross) were computed utilizing the Uniform Charge Structure. Net Revenues are derived by reducing Gross Revenue by a Contractual Allowance, which is the difference between the Charges and the Actual Projected Payments for Fee for Service Payors. Insurance/Private Pay Charges were reduced for Bad Debts and Discounts. Intrepid New Agency - SSDR 8 Americus, Georgia Assumptions for the Pro-forma Financial Statements Page 3 Coutractual Adjustments: Contractual Adjustments for Medicare are reflected as the difference between Charges and the Medicare Average PPS Rate for the Albany Agency for 2005 of$3,174.25. Contractual Adjustment for Medicaid is the difference between Charges and the Medicaid Cost. Indigent Care Contractual is equal to Gross Charge, as no Revenue will be derived from these services. Bad Debts were computed as 5% of Gross Insurance/Private Pay Charges. Insurance/Private Pay was discounted by 10% of Gross Insurance/Private Pay Charges. Direct Labor Costs (Visiting) & Administrative: (Based upon 12/31/2005 Medicare Cost Report for the Albany, Georgia Agency. Year 1 Year 2 - Position 2007 - 2008 2008 - 2009 Skilled Nursing $29.48/Visit $30.22/Visit Phvsica] Therapy $44.85/Visit $45.97/Visit Oceup. Therapv $39.60/Visit $40.59/Visit Speech Theraov $40.00/Visit $41.00/Visit Medical Soc. Servo $40.00/Visit $41.00IVisit Home Health Aide $] O.83/Visit $] 1.l0IVisit Administrator $65,OOO/Per Annum $66,625/Per Annum Asst Administrator/Directors $56,OOO/Per Annum $57,400/Per Annum Marketing $34,OOOIPer Annum $34,850/Per Annum Other Admin. Personnel $32,250/Per Annum $33,056/Per Annum Fringe Benefits ] 6.87% / Wages 16.87% / Wages Labor Related Costs were increased by 2.5% between Year I (2007 - 2008) and Year 2 (2008- 2009). Fringe Benefits are projected to be 16.87% of Gross Wages for all employees. Intrepid New Agency - SSDR 8 Americus, Georgia Assumptions for the Pro-forma Financial Statements Page 4 Other Indirect Non-Labor Costs: All other administrative costs wcre projected to increase by 2.0% between each tiscal year. Agency Rent for Year 1 & Year 2 is estimated to be $750.00 per month or $9,000 per annum. Amortization Expense is estimated to be $20,000.00 for CON related expenses and $50,000.00 for Start-up related expenses amortized over 5 years or $14,000.00 per year. Full Time Equivalents: Year I Year 2 Position 2007 - 2008 2008 - 2009 Skilled Nursing 3.52 4.69 Phvsica] Theraov 2.12 2.83 Occuoational Theraov 0.34 0.45 Soeech Therapy 0.08 0.10 Medical Social Worker 0.12 0.]5 Home Health Aide 1.39 1.85 Administrator 1.00 1.00 Asst Admin.! Directors 1.09 1.54 Marketing 1.00 1.00 Other Admin. Personnel 3.97 5.50 Total 14.63 19.11 Full time equivalents were computed as follows: All disciplines, except for Medical Social Services, were based upon a 260-day work year performing 5 visits per day. Medical Social Services, was based upon a 260-day work year pertcllming 3 visits per day. Administrative staff was based upon 2080-hour work year. Intrepid New Agency - SSDR 8 Americus, Georgia Assumptions for the Pro-forma Financial Statements Page 5 Average Cost Per Visit: Year I Year 2 . 2007 - 2008 2008 - 2009 A verage Cost per Visit 103.38 103.26 Medicare Cost per Visit 102.71 102.58 Medicaid Cost per Visit 102.75 102.69 Indigent Cost per Visit 103.38 103.26 Ins. / Pvt. Pay Cost oer Visit 11 0.47 110.44 Net Charges Per Visit: Year 1 Year 2 2007 - 2008 2008 - 2009 Average Net Charge per Visit 141.09 141.48 Medicare Net Charge oer Visit 150.01 150.01 Medicaid Net Charl!:e oer Visit 86.41 86.70 . Indigent Net Charge oer Visit 0.00 0.00 los.lPv!. Pay Charge per Visit 137.85 141.89 Rounding: It should be noted that variances might be reflected between the Projected Financial Statements and the Assumptions. These variances are due to rounding when computations were calculated in the spreadsheets as the spreadsheets carry computations out 9 places. These variances are expected to be immaterial, however, they do exist. INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, QUITMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT Year 1 VISIT ESTIMATE = 9,772 REVENUES: INSURANCE MEDICARE MEDICAID INDIGENT PRIVATE TOTAL 1,317,896 88,513 45,768 132,985 1,585,161 99 350 41,332 45,768 19,948 206.398 1,218,546 47,180 0 113,037 1,378,763 MEDICAL SERVICE REVENUES LESS ALLOWANCES TOTAL NET REVENUE EXPENSES: DIRECT PATIENT CARE ADMINISTRATIVE LABOR AGENCY ADMIN. & GENERAL TOTAL AGENCY EXPENSES INCOME BEFORE TAXES STATE INCOME TAX FEDERAL INCOME TAX TOTAL TAX NET INCOME (LOSS) 335,423 22,546 11,686 33,860 403,515 279,860 18,811 9,750 28,251 336,672 219,018 14,743 7.821 28.470 270,051 834,300 56,100 29.257 90,581 1 ,01 0,239 384,246 (8,920) (29,257) 22,456 368,525 23,055 (535) (1,755) 1,347 22,111 108,357 12,515) 18,250) 6,333 103,924 131,412 (3,051) (10,006) 7,680 126,035 252,834 (5,869) (19,251) 14,776 242,489 150,01 86.41 0,00 137.85 141,09 102,71 102,75 103,38 110.47 103,38 Average Net Charge Per Visit Average Cost Per Visit INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, aUlTMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TAlBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR 1 VISIT ESTIMATE" 9,172 JUl2007 AUG2007 SEP2007 OCT 2007 NOV2007 DEC2007 JAN200B FEB2008 MAR 2008 APR2008 MAY 2008 JUN200B TOTAL REVENUES MEDICARE SKILLED NURSING $14,685 $25,410 $48,840 $53,460 $54,780 $56,595 $57,750 $59,235 $60,720 $62,205 $63,525 $69,630 $626,835 PHYSICAL THERAPY 9,990 17,205 33,115 36,075 37,185 38,295 39,035 40,145 41,070 41,995 42,920 46,990 424,020 SPEECH THERAPY 370 555 1,295 1.295 1,295 1.480 1.480 1,480 1,480 1,480 1,480 .1.665 15,355 OCCUPATIONAL THERAPY 1,665 2,775 5,365 5,920 6,105 6,290 6,290 6,475 6,660 6,845 7,030 7,585 69,005 MEDICAL SOCIAL WORKER 370 555 1,110 1,295 1,295 1,295 1,295 1,480 1,480 1,480 1,480 1,665 14,800 HOME HEALTH AIDE 3,150 5,490 10,530 11,430 11,790 12,150 12,420 12,690 13.050 13,320' 13,680 14,940 134,640 MEDICAL SUPPLIES 779 1,348 2.590 2,835 2,905 3.001 3.063 3,141 3,220 3.299 3,369 3,693 33,241 .------ --._--- 00__00- ------ __00_- __00_-- __00_--- ------ ____00_- __00- ------ ___00_- ---- SUBTOTAL 31,009 53,338 102,845 112,310 115,355 119,106 121,333 124,646 127,680 130,624 133,484 146,168 1,317,896 00__00- ---- 00_00- ----- _00__- MEDICAID SKILLED NURSING 990 1,650 3,300 3,630 3,795 3,795 3,960 3,960 4,125 4,290 4,290 4,785 42,570 PHYSICAL THERAPY 740 1,110 2,220 2.405 2,590 2,590 2,590 2,775 2,775 2,775 2,960 3,145 28,675 SPEECH THERAPY 0 0 0 0 0 185 185 185 185 185 185 185 1.295 OCCUPATIONAL THERAPY 185 185 370 370 370 370 370 370 370 555 555 555 4,625 MEDICAL SOCIAL WORKER 0 0 0 0 0 0 0 0 0 0 0 0 0 HOME HEALTH AIDE 180 360 720 810 810 810 810 900 900 900 900 990 9,090 MEDICAL SUPPLIES 53 88 175 ,.3 201 201 210 210 21. 228 228 254 2.258 ------ ---- ----- ------- -._---- .---- ----00 00__- 00___- _____00 ------ _00_- ----- SUBTOTAL 2,148 3,393 6,785 7.408 7,766 7,951 8,125 8,400 8,574 8,933 9,118 9,914 88,513 ._n___ ----- --.._- ____00 ____00- __00- __nn 00__- 00___- 00___00- u___ _00___- _n___ INDIGENT SKILLED NURSING 495 990 1,815 1,980 1,980 1,980 2.145 2,145 2,145 2.310 2,310 2,475 22,770 PHYSICAL THERAPY 370 555 1,110 1,295 1,295 1,295 1.480 1.480 1.480 1.480 1.480 1,665 14,985 SPEECH THERAPY 0 0 0 0 0 0 0 0 0 0 0 0 0 OCCUPATIONAL THERAPY 0 185 185 185 185 185 185 185 185 185 185 185 2,035 MEDICAL SOCIAL WORKER 0 0 0 0 0 0 0 0 0 0 0 0 0 HOME HEALTH AIDE 90 180 360 450 450 450 450 450 450 450 450 540 4,770 MEDICAL SUPPLIES 26 53 96 105 105 105 114 114 114 123 123 131 1,208 ----.. ___00- _00___- ------ __00- ------ -----.. 00__- ___n_ _h_ ------ --.- SUBTOTAL 981 1,963 3,566 4,015 4;015 4,015 4,374 4,374 4,374 4,548 4,548 4,996 45.768 ..u__ --_00- n_n_._ ---- u___n ---- ---.. 00_- 00__00_- -____00 -"-- _00___- __u_ INSURANCEIPRIVATE PAY SKilLED NURSING 1.485 2.475 4,950 5,280 5,445 5,610 5,775 5,940 6,105 6,270 6.435 6.930 62,700 PHYSICAL THERAPY 925 1,665 3,330 3,700 3,700 3,885 3,885 4,070 4,070 4,255 4,255 4,810 42,550 SPEECH THERAPY 0 0 185 165 185 185 185 185 185 185 185 185 1,850 OCCUPATIONAL THERAPY 185 370 555 555 555 555 555 740 740 740 740 740 7,030 MEDICAL SOCIAL WORKER 0 0 185 185 185 185 185 185 185 185 185 165 1,850 HOME HEALTH AIDE 360 540 1,080 1,170 1,170 1,260 1,260 1,260 1,350 1,350 1,350 1,530 13,680 MEDICAL SUPPLIES 79 131 263 280 289 298 306 315 324 333 341 368 3.325 ------ --- n___n ---.- __h_ ______n __u__ --- ___u 00___- ---- --.----- ------- SUBTOTAL 3,034 5,181 10,548 11,355 11,529 11,978 12,151 12,695 12.959 13,318 13.491 14,748 132,985 _00__- ___00- _00_0000 ------- --__00 _n__.__ ------ ..----- ___.u__ 00_____- ------ __n_'_' TOTAL REVENUE 37,171 63,874 123,744 135.088 138,665 143,050 145.983 150,115 153,586 157.421 160,640 175,825 1,585,161 lESS AlLOWANCE.MEDICARE 2,338 4,021 7,753 8,467 8,696 8,979 9,147 9,397 9,625 9,847 10,063 11,019 99,350 -MEDICAID 1,003 1.584 3,168 3.459 3,627 3.713 3,794 3,923 4.004 4,171 4.258 4,629 41,332 -INDIGENT 961 1,963 3,566 4,015 4,015 4,015 4,374 4,374 4,374 4,548 4,548 4,996 45,768 -INSURANCE/PRIVATE PAY 303 518 1,055 1,136 1,153 1,198 1,215 1,270 1,296 1,332 1,349 1.475 13,299 -BAD DEBT 152 259 527 568 576 599 608 635 648 666 675 737 6,649 NET REVENue $32,395 $55,529 $107,674 $117,444 $120,598 $124,547 $126,845 $130,518 $133,640 $136.858 $139,749 $152,968 $1,378,763 INTREPID NEW AGENCY SSDR S SERVICING CHATTAHOOCHEE, CLAY, HARRIS,'MACON, MARION, aUlTMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR 1 VISIT ESTIMATE" 9,772 JUL2007 AUG2007 SEP2007 OCT 2007 NOV2007 DEC2007 JAN2008 FEB2008 MAR 2008 APR2008 MAY 2008 JUN2008 TOTAL EXPENSES DIRECT SKILLED NURSING P\R $3,155 $5,454 $10,525 $11,498 $11,793 $12,147 $12,442 $12,737 $13,061 $13,415 $13,680 $14,977 $134,885 FRINGE BENFITS 532 920 1,776 1,940 1,990 2,049 2,099 2,149 2.203 2,263 2,308 2,527 22,755 TR,WEL 301 520 1,004 1.096 1,125 1,158 1,186 1,215 1,245 1,279 1,304 1,428 12.862 SUBTOTAL 3,988 6,895 13,305 14,535 14,907 15,355 15,727 16,100 16,510 16,957 17,293 18,932 170,503 PHYSICAL THERAPY PIR 2,915 4,978 9,643 10,540 10,854 11,168 11,392 11,751 11,975 12,244 12,513 13,724 123.698 FRINGE BENFITS 492 840 1,627 1,778 1,831 1,884 1,922 1,982 2,020 2,066 2,111 2,315 20,868 TRAVEL 278 475 920 1,005 1,035 1,065 1,086 1.121 1.142 1,168 1,193 1,309 11,795 CONTRACT 0 0 0 0 0 0 0 0 0 0 0 0 0 SUBTOTAL 3,685 6,293 12,189 13,323 13,720 14,117 14,400 14,854 15,137 15,477 15,818 17,348 156,361 SPEECH THERAPY 80 120 320 320 320 400 400 400 400 400 400 440 4,000 FRINGE BENFITS 13 20 54 54 54 67 67 67 67 67 67 74 675 TRAVEL 8 11 31 31 31 3B 38 38 38 38 38 42 381 CONTRACT 0 0 0 0 0 0 0 0 0 0 0 0 0 SUBTOTAL 101 152 404 404 404 506 506 506 506 506 506 556 5,056 OCCUPATIONAL THERAPY 436 752 1,386 1,505 1,544 1,584 1,084 1,663 1,703 1,782 1,821 1,940 17,700 FRINGE BENFITS 73 127 234 254 261 267 267 281 287 301 307 327 2,986 TRAVEL 42 72 132 143 147 151 151 159 162 170 174 185 1,688 CONTRACT 0 0 0 0 0 0 0 0 0 0 0 0 0 SUBTOTAL 551 951 1,752 1,902 1,952 2,002 2,002 2.102 2,152 2,252 2,302 2.453 22,374 MEDICAL SOCIAL WORKER 80 120 280 320 320 320 320 360 360 360 360 400 3,600 FRINGE BENFITS 13 20 47 53 53 53 53 60 60 60 60 67 600 TRAVEL , 11 27 31 31 31 31 34 34 34 34 36 343 CONTRACT 0 0 0 0 0 0 0 0 0 0 0 0 0 SUBTOTAL 101 151 353 404 404 404 404 454 454 454 454 505 4,543 HOME HEALTH AIDE PIR 455 790 1,527 1,667 1,711 1,765 1,797 1,840 1,895 1,927 1,970 2,165 19,509 FRINGE BENFITS 77 133 258 281 289 296 303 311 320 325 333 365 3,293 TRAVEL 43 75 146 159 163 168 171 176 181 184 188 206 1,860 SUBTOTAL 575 999 1,930 2,108 2,162 2,231 2,272 2,327 2,395 2,436 2,491 2,737 24,663 MEDICAL SUPPLIES 468 809 1,562 1,706 1,750 1,1303 1,846 1,890 1,938 1,991 2,030 2,223 20,016 _nn_n ____n__ n__nn ______n ___n_n ____n__ __n____ -------- --"----- __n__ ------- TOTAL DIRECT $9,468 $16,250 $31,495 $34,382 $35,300 $36,416 $37,157 $38,233 $39,093 $40,074 $40,893 $44,754 $403,515 INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, QUITMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR 1 VISIT ESTIMATE" 9,772 EXPENSES JUL2007 AUG2007 SEP2007 OCT 2007 NOV2007 DEC20Q7 JAN 2008 FEB2008 MAR 2008 APR 2008 MAY 2008 JUN2008 TOTAL OVERHEAD ADMINISTRATOR $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $5,417 $65,004 ASST ADMIN i DIRECTORS 5,087 5,087 5,087 5,087 5,087 5,087 5,087 5.087 5,087 5,087 5.087 5,087 61,044 MARKETING 2,833 2.833 2,833 2.833 2.833 2.833 2.833 2,833 2,833 2,833 2,833 2,833 33,996 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 CLERICAL 10,669 10.669 10,669 10.669 10,669 10,669 10,669 10,669 10,669 10,669 10,669 10,669 128,028 FRINGE BENFITS 4.050 4,050 4,050 4,050 4,050 4,050 4,050 4,050 4,050 4,050 4,050 4,050 48.600 REPAIRS & MAl NT. 72 72 72 72 72 72 72 72 72 72 72 72 864 TRANSP I AUTO EXPENSE 2,543 2,543 2,543 2,543 2,543 2,543 2,543 2,543 2,543 2,543 2,543 2,543 30,516 TRAVEL l LODGING I CONFERENCES 68 68 68 68 68 68 68 68 68 68 68 68 816 COMMUNITY EDUCATION l ADVERTISING 545 545 545 545 545 545 545 545 545 545 545 545 6,540 CONTRACTED SVCS. ICONSUL TING 37 37 37 37 37 37 37 37 37 37 37 37 444 DUES & SUBSCRIPTIONS 29 29 29 29 29 29 29 29 29 29 29 29 348 COMMUNICATION I TELEPHONE 1,746 1.146 1,746 1.146 1,746 1,746 1,746 1,746 1,746 1,746 1,746 1,746 20,952 EQUIPMENT RENT! COMPUTERS 0 0 0 0 0 0 0 0 0 0 0 0 0 JANITORAL I PLANT OP 190 190 190 190 190 190 190 190 190 190 190 190 2,280 LICENSE & TAXES 141 141 141 141 141 141 141 141 141 141 141 141 1,692 OFFICE SUPPLIES 728 728 728 728 728 728 728 72B 728 72B 728 72B 8,736 POSTAGE & COURIERS 196 196 196 196 196 196 196 196 196 196 196 196 2,352 HOME OFFICE ALLOCATION 10,966 10,966 10,966 10,966 10,966 10,966 10,966 10,966 10.966 10,966 10,966 10,966 131,592 EXPENSE CONTINGENCY 0 0 0 0 0 0 0 0 0 0 0 Q 0 DEPRECIATION 17 17 17 17 17 17 17 17 17 17 17 17 204 AMORTIZATION OF CAPITAL COST 1,167 1,167 1.167 1,167 1,167 1,167 1,167 1,167 1.167 1,167 1,167 1,167 14.004 BUILDING RENTAL 750 750 750 750 750 750 750 i'50 750 750 750 75il 9,000 UTILITIES 313 313 313 313 313 313 313 313 313 313 313 313 3,758 RESERVED 2,996 2,996 2,996 2,996 2,996 2,996 2,996 2,996 2,996 2.996 2,996 2,996 35,953 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 ------ ------- -------- ------- ------- -------- ------- ------- ------- -------- ____n_ -- --- ---- TOTAL OVERHEAD COST $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $50,560 $606,723 -------- ------- ------ ------- -------- ------- ------- ------- ------- ------- -------- -------- TOTAL EXPENSE $60,029 $66,B11 $82,056 $84,942 $B5,860 $86,977 $87,717 $88,793 $89,653 $90,634 $91,454 $95,314 $1,010,239 ----- -------- -------- -------- -------- -------- ------- ------- -------- ______n AVG. COST PER VISIT $262.13 $169.57 $107.54 $101.97 $100.42 $98,61 $97.46 $95.99 $94.67 $93.44 $92.38 $87.93 $103.38 VISIT ESTIMATE = DISCIPLINE SKILLED NURSING PHYSICAL THERAPY SPEECH THERAPY OCCUPATIONAL THERAPY MEDICAL SOCIAL WORKER HOME HEALTH AIDE MEDICAL SUPPLIES TOTALS Medicare Per Patient Avg Visits per Patients DISCIPLINE SKILLED NURSING PHYSICAL THERAPY SPEECH THERAPY OCCUPATIONAL THERAPY MEDICAL SOCIAL WORKER HOME HEALTH AIDE MEDICAL SUPPLIES TOTALS RECONCILIATION OF COST: INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, aUlTMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR 1 TOTAL DIRECT COST FROM FIN STMTS TOTAL A&G COST FROM FIN STMTS HOME OFFICE ALLOCATION TOTAL COST LESS NONALLOWABLE COSTS TOTAL REIMBURSABLE COST 9,172 TOTAL DIRECT OVERHEAD VISITS COST COST 4,575 $170,503 $260,678 2.758 156,361 $239,057 100 4,000 $6,116 447 17,700 $27.061 90 3,600 $5.504 1,802 24,663 $37,706 20.016 $30,601 9,772 $396,842 $606,723 40.61 62.09 No. Avg PPS Gross Patients Pm! Revenues 384 3,174.25 1,218.546 21.16 3,174.53 1.225,370,00 $403,515 475,131 131592 $1,010,239 Q $1.010.239 REIMB. COST MEDICARE MEDICARE COST LIMIT MEDICARE MEDICARE CONTRACT. CAP COST PER VISIT VISITS COST PER VISIT COST LIMIT CHARGES ADJUST. SPACE $431,181 $94.25 3.799 $358,045 $92.41 $351.081 $626.835 395,418 $143.37 2.292 328.607 $103.54 237,316 424,020 10,116 $101.16 83 8,396 $108.18 8,979 15,355 44,762 $100.14 373 37,351 $105.34 39,292 69,005 9.104 $101.16 80 5,092 $143.42 11,474 14,800 62,369 $34.61 1,496 51,778 $38.59 57.732 134,640 50.617 42,032 42,032 33,241 $1,003,565 $102.70 8,123 $834,301 $747,905 $1.317,896 $569.991 ($86.395) 102.70 $102.71 $92.07 MEDICAID MEDICAID COST LIMITS MEDICAID STATE WIDE STATE WIDE MEDICAID CONTRACT. CAP VISITS COST PER VISIT COST LIMIT AVG RATE AVG REV. CHARGES ADJUST. SPACE 258 $24,316 $92.41 23,843 $72.61 $18.733 $42,570 155 22.223 $103.54 16,049 $72.61 11,255 28,675 7 708 $108,18 757 $72.61 508 1,295 25 2,503 $10534 2.634 $7261 1,815 4,625 0 0 $143.42 0 $72.61 0 0 101 3.496 $38,59 3,898 $72.61 7,334 9,090 2,854 2.854 2,258 -s46 $56,100 47,180 $42.500 $88,513 $41,332 (13,600) 102.75 77,84 REIMBURSABLE MEDICAL SUPPLIES: CHARGES RATIO COST MEDICARE $33,241 0.8304 42,032 MEDICAID 2.258 0.0564 2,854 INS/PRIVATE 3,325 0.0831 4,204 INDIGENT 1.208 0.0302 1,527 nn____ TOTAL $40,031 $50,617 INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, QUITMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT Year 2 VISIT ESTIMATE = 13,027 REVENUES: INSURANCE MEDICARE . MEDICAID INDIGENT PRIVATE TOTAL 1,809,749 122,534 61,944 182,458 2,176,685 185,271 59,067 61,944 27,369 333,651 1,624,478 63,467 0 155,089 1,843,034 MEDICAL SERVICE REVENUES LESS ALLOWANCES TOTAL NET REVENUE EXPENSES: DIRECT PATIENT CARE ADMINISTRATIVE LABOR AGENCY ADMIN. & GENERAL TOTAL AGENCY EXPENSES INCOME BEFORE TAXES STATE INCOME TAX FEDERAL INCOME TAX TOTAL TAX NET INCOME (LOSS) 458,376 30,984 15,789 46,265 551,414 361,362 24,427 12,447 36,473 434,709 291 ,094 19,756 10,282 37,977 359,109 1,110,832 75,167 38,518 120,716 1 ,345.232 513,646 (11,700) (38,518) 34,374 497,802 30,819 (702) (2,311) 2,062 29,868 144,848 (3,299) (10,862) 9,693 140,380 175,667 (4,001) (13,173) 11,756 170,248 337,979 (7,699) (25,345) 22,618 327,554 150.01 86.70 0.00 141.89 141.48 102.58 102.69 103.26 110.44 103.26 Average Net Charge Per Visit Average Cost Per Visit INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARR15, MACON, MARION, QUITMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYlOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR 2 VISIT ESTIMATE.. 13,027 JUl2008 AUG200B SEP2008 OCT200a NOViWOe DEC2008 JAN2D09 FEB2D09 MAR 2009 APR20D9 MAY2OD9 JUN2D09 TOTAL = SKIUED NURSING 50. 50. 508 50. 508 508 50. 50. 508 50. 508 511 8.099 PHYSICAL THERAPY '07 307 307 307 307 307 307 '07 307 307 307 308 ',6ll5 SPEECH THERAPY 11 11 11 11 11 11 11 11 11 11 11 11 132 OCCUPATIONAL THERAPY " " " " " " " " " " " 51 590 MEOICAL SOCIAL WORKER 10 10 10 10 10 10 10 10 10 10 10 10 120 HOME HEALTH AIDE 200 200 200 200 200 200 '00 200 '00 200 '00 201 2,401 -- - -- -- - - - - - - -- - -- TOTAL 1,085 1,085 1,065 1,085 1,085 1,085 1,085 1,085 1,085 1,085 1,085 1,002 13.027 vISITS BY DISCIPL/NEJPAYOR SOURCE SKillED NURSING MEDICARE '22 '" 422 '22 42' 422 422 422 422 422 422 424 5,066 MEDICAID 29 29 " 29 29 " 29 29 29 29 " 29 34. INDIGENT 15 15 15 15 15 15 15 15 15 15 15 15 180 INSURANCE/PRIVATE PAY 42 42 42 42 42 42 42 42 42 42 42 " 505 PHYSICAL THERAPY MEDICARE 255 '59 '59 255 '" 255 '59 '" '59 255 '59 '56 3,081 MEDICAle 17 17 17 17 17 17 17 17 17 17 17 17 '04 INDIGENT 9 9 9 9 9 9 9 9. 9 9 9 9 108 INSURANCE/PRIVATE PAY ,. 26 26 28 28 28 26 28 26 28 " ,. '12 SPEECH THERAPY MEDICARE 9 9 9 9 9 9 9 9 9 9 9 9 108 MEDICAID 1 1 1 1 1 1 1 1 1 1 1 1 12 INDIGENT 0 0 0 0 0 0 0 0 0 0 0 0 0 INSURANCE/PRIVATE PAy 1 1 1 1 1 1 1 1 1 1 1 1 12 OCCUPATIONAL THERAPy MEDICARE 41 41 41 41 41 41 41 41 41 41 41 42 49' MEDICAID , , , , , , , , , , , , 36 INDIGENT 1 1 1 1 1 1 1 1 1 1 1 , 13 INSURANCE/PRIVATE PAY 4 4 4 4 4 4 4 4 4 4 4 4 " MEDICAL SOCIAL WORKER MEDICARE , 9 , 9 , , 9 9 , , 9 , 10. MEDICAlO 0 0 0 0 0 0 0 0 0 0 0 0 0 INDIGENT 0 0 0 0 0 0 0 0 0 0 0 0 0 INSURANCE/PRIVATE PAY 1 1 1 I I 1 1 1 1 I 1 1 12 HOME HEALTH AIDE MEDICARE 166 165 166 166 166 '66 '66 16. 166 166 '66 167 1,993 MEDICAID 11 11 11 11 11 11 11 11 11 11 11 11 '32 INDIGENT . . 9 . . . . . . . . . 72 INSURANCE/PRIVATE PAY 17 17 17 17 17 17 17 17 17 17 17 17 '04 TOTAL VlStTS MEDICARE 902 902 90' 902 902 902 902 902 90' 902 902 807 10,829 MEDICAID 61 61 61 61 61 61 61 61 61 61 61 61 732 INDIGENT 31 31 31 31 31 31 31 31 31 31 31 32 37' INSURANCE/PRIVATE PAY 61 91 91 91 91 91 91 91 91 91 91 92 1,093 -- - - - - --- - --- - - - -- -, TOTAL 1,065 1,065 1,085 1.085 1,065 1,085 1,085 1,085 1.065 1,085 1,085 1,092 13,027 ==..== ..- === s::=s::= =".... ....-.. ",,=.. === ..."..." ........ ..."" % VISITS PER MONTtl 8.:l30/0 8.33% 8.33'" 8.33% 8.33% e.33% 8.33% 8.33% 8,33% 8,33% t133% 8.:l7% 100.00% INTREPID NEW AGENCY S50R 11 SERVICING CHATTAHOOCHEE, CLAY, HA.RRIS, MACON, MARION, QUITMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT VEAR2 VISIT ESTIMATE" 13,D27 JUL2008 AUG200a SEP2008 OCT 2008 NOV20I;lB DEC2008 JAN201;l9 FEB2009 MAR 2009 APR2009 MAV2009 JUN2009 TOTAl.. ~ ~ SKILLED NURSING $71,719 $71,719 $71,719 $71,719 $11,719 $71,719 $71,719 $71,719 $71,719 $71,719 $71,719 $72,059 $860,967 PHYSICAL THeRAPY 48,590 48,590 48,590 48,590 48,590 4a,590 48.590 48,590 48,590 48,590 48,500 48,781 583,274 SPEECH THERAPY 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 20,579 OCCUPATIONAL THERAPY 7,813 7,813 7,813 7,813 7,613 7,813 7,813 7,813 7,813 7,813 7,613 8,003 93,941 MEDICAL SOCIAL WORKER 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 20,579 HOME HEALTH AIDE 15,388 15,388 15,388 15,38S 15,368 16,388 15,388 15,388 15,388 15,388 15,388 15,461 184,751 MEDICAL SUPPLIES 3,803 3,803 3,803 3,803 3.803 3,803 3,803 3,803 3,803 3,803 3.803 3,821 45,657 ~--- ----- ----- -- ----- ---- --- -- --- --- --- --- - SUBTOTAL 150,743 150,743 150,743 150,743 15D,743 150,743 150,743 150,743 150,743 150,743 150,743 151,575 1,809,149 -- .--- ---- --,- ---- -- --- --- --- -- - ---- -- ~ SKilLED NURSING 4,929 4,929 4,929 4,929 4,929 4.m 4,929 4,929 4,929 4,929 4,929 4,9.29 59,143 PHYSICAL THERAPY 3,239 3,239 3,239 3,239 3,239 3,239 3,239 3,239 3.239 3,239 3,239 3,239 M,872 SPEECH THERAPY 191 191 191 191 191 191 191 191 191 191 191 191 2,287 OCCUPATIONAL THERAPY "2 ." ." ." ." ." "2 ." ." ." 572 5" 6,880 MEDICAL SOCIAL WORKER 0 0 0 0 0 0 0 0 0 0 0 0 0 HOME HEALTH AIDE 1,020 1.020 1,020 1.020 1,020 1,020 1,020 1,020 1,020 1,020 1,020 1,020 12,23e MEDICAL SUPPlIES 261 261 2tl1 261 261 261 261 261 2., 261 261 2" 3,136 .---- -- - -- --- ---- --- --- --- ......-. --- --- -- SUBTOTAL 10,211 10,211 10,211 10,211 10,211 10,211 10,211 10,211 10,211 10,211 1D,211 10,211 122,53<1 --- .--- --- - -.--.-. ---- ---- - -- -- -- --- ,-- lliOIllOO SKILLED NURSING 2,5<$9 2,549 2,':A9 2,M9 2,549 2.549 2,549 2,549 2,549 2,549 2,549 2,549 30,5&1 PHYS\Cllt,L THERAP'Y 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,715 1,7115 1,715 1,715 20,579 SPEECH THERAPY 0 0 0 0 0 0 0 0 0 0 0 0 0 OCCUPATIONAL THERAPY 191 191 191 191 191 191 191 191 191 191 191 381 2,477 MEDICAL SOCIAL WORKER 0 0 0 0 0 0 0 0 0 0 0 0 0 HOMe HEALTH AIDE 5,. 5,. .38 .,. ". .,. .,. .,. .,. ... ". .,. 6,674 MEDICAL SUPPUES ". '" 135 135 '" 135 ". 135 ". "5 '" 135 1,622 - -- -- --.- -- - .--. .--- - -- ---- --- -- SUBTOTAl 5,1<$6 5,146 5,146 5,146 5,146 5,146 5,146 5,146 5,145 5,146 5,146 5.337 151,944 ---- --- -- --- .--- ---- ----- -- - - ,- - - INSURANCE/PRIVATE PAY SKILLED NURSING 7,138 7,138 7,138 7,138 7,138 7,138 7,138 7,138 7,138 7,1:38 7,138 7,308 85,825 PHYSICAL THERAPY 4.954 4,954 4,954 4,954 4,954 4,954 4,954 4.954 4,954 4,954 4.954 4,954 S9,452 SPEECH THERAPY 191 191 191 191 191 191 191 191 191 191 191 191 2,287 OCCUPATIONAL THERAPY '62 "2 762 "" '62 "2 762 7.2 '62 7'2 '62 7.2 9,146 MEDICAL SOCIAL WORKER 191 191 191 191 191 191 191 191 191 191 191 191 2,287 HOME HEALTH AIDE 1,5713 1,576 1,576 1.57e 1,576 1,576 1,576 1,576 1,576 1.576 1,576' 1,576 16,911 MeOICAL SUPPUES 379 379 379 379 379 37. 379 379 379 '" 379 3S9 4,551 --- --- .--- -.------ -_.- --- -- -~ SUBTOTAL 15,190 15,190 15,190 15,190 15,190 15,190 15,190 15,190 15,190 15,190 15,190 15,369 182.458 --- .---- - _u_ ,- --- -- -- -- - - -- ,- TOTAL REVENue 181,290 181,290 181,290 181,290 161,290 181,290 181,290 181,290 181,290 181,290 181,290 1&2,492 2,178,685 lESS ALlOWANCE-MEDlCARE 15,432 15,432 15,432 15.-432 15,432 15,432 15,432 15,432 15,432 15,432 15,432 15,517 165,271 -MEDICAID 4,922 .0:,922 4,922 4,9.22 4,922 4,922 4,922 4,922 4.922 4,922 4,922 4,922 59,067 -INDIGENT 5,146 5,146 5,146 5,146 5.146 5.146 5,146 5,146 5,146 &,146 5,'146 5,337 61,944 -INSURANCE/PRIVATE PA V 1,519 1,519 1,519 1,519 1,5'\9 1,519 1,519 1,519 1,519 1.519 1,519 1,537 18,246 -BAD DeeT 7&9 "9 '59 759 '" 759 "9 '59 759 759 759 ,.. 9,123 NET REVENUE $153,511 $153,511 $153,511 $153,511 $153,511 5153,511 $153,511 5153.511 $153,511 $153,511 $153,511 $164,410 $1,843,034 INTREPID NEW AGENCY SSOR 8 SERVICING CHATTAHOQCHEE, CLAY, HARRIS, MACON, MARION, QUlTMAN, RANDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYlOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT \'EAR 2 VISIT ESTIMATE. 13,027 JUl..200B AUG2008 SEP2008 OCT 2008 NDV2008 OEC200B JAN200e FEB2009 MAR2<lD9 APR 2009 MAY 2009 JUN2009 TOTAL ~ 0lBill SKILLED NURSING P\R $15,S52 $15,352 $15,352 $15,352 515,352 815,352 $15,352 S15,352 $15,352 $15,352 $15,352 $15.443 $184,313 FRINGE BENFITS 2,590 2,590 2,590 2,590 2,590 2,590 2,590 2,590 2,590 2,590 2,590 2,605 31,094 TRAVEL 1,457 1,457 1.457 1.457 1,457 1,457 1.457 1.457 1,457 1,457 1,457 1,465 17,4t!9 SUBTOTAL 19,398 19,398 19,398 19,3S8 19,396 19,398 19,398 19,398 19,398 19,398 19,398 19,513 232,896 PHYSICAL THERAPY PIR 14,113 14,113 14,113 14,113 14,113 14,113 14,113 14,113 14,113 14,113 14,113 14,159 169,406 FRrNGE BENFITS 2,381 2,361 2,381 2,381 2,361 2,361 2,381 2,381 2,381 2,381 2,381 2,389 28,579 TRAVEL 1,339 1.339 1,339 1,339- 1,3;;9 1,359 1,339 1,339 1,339 1,339 1,339 1,344 1e.o75 CONTRACT 0 . . . . . . . . 0 0 . . SUBTOTAL 17,83:J. 17,833 17,6S3 17,833 17,833 17,833. 17,833 17,833 17,S33 17,833 17,S33 17,892 214,060 speeCH THERAPY .51 '" '" '" '" 451 451 .51 .51 45' 45' '" 5,412 FRfNGE BENF1TS '" '" '" '" '" " 7. 7. " " 7. 7. ." TRAvel " " " " " " " " " " " " 51. CONTRACT . . . . 0 0 . . . . . . 0 SUBTOTAL 57. 57. 57. 57. 570 570 57. 57. 57. 570 '70 570 6,639 OCCUPATIONAL THERAPY 1,989 1,989 1,989 1,989 ',969 1,989 1,969 1,969 1,989 1,989 1,989 2,070 23,947 FRINGE. BENFITS 338 336 336 336 330 338 336 338 '38 336 '" 349 ',040 TRAVEL '" '" '" '" '" ". '" '" '" '" '" '" 2,272 CONTRACT . 0 . 0 . . 0 0 . 0 0 . . SUBTOTAL 2,513 2,513 2,513 2,513 2,513 2,513 2,513 2,513 2,513 2,613 2,513 2,616 30,259 MEOICAL SOCIAL WORKER 410 41. 41. 41. 41. 410 ." 410 41. 41. 410 41. 4,920 FRINGE. BENFITS ., .. .. " " .. ., ., e, .. " .. 62. TRAVEL " " " " " " " " " " 39 " 457 CONTRACT . . . 0 . . 0 . . . 0 . . SUBTOTAL 517 517 517 '" 517 5" 5" '" 5" 517 617 '" 6,207 HOME HEALTH AIDE P\R 2,219 2,219 2,219 2.219 2,219 2.219 2,219 2,219 2,219 2,219 2,219 2,231 26,644 FRINGE BENFfTS '" '" '" 375 '" 37' 315 '" '" 375 '75 377 4,498 TRAVEL 211 211 211 211 211 211 211 211 211 211 211 2" 2,528 SUBTOTAL 2,605 2,805 2,805 2,805 2,605 2,a05 2,805 2,805 2,805 2,805 2,605 2,819 33,670 MEDICAL SUPPLIES 2,269 2,289 2,m 2,289 2,269 2,289 2,289 2,269 2,269 2,2sa 2,289 2,303- 27,454 .-- --- --.- .- -.- --- -- ..._. -- - - - --- TOTAL DIRECT $45,926 $45,926 545,926 $45,926 $45,926 .145,926 $45,926 $45,926 $45,926 $45,926 $45,926 $46,229 $551,4101 -..-- ------ INTREPID NEW AGENCY SSDR 8 SERVICING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, aUlTMAN, RANDOLPH, SCHLEY, STEWART, SUMTER, TAL60T AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR 2 VISIT ESTIMATE '" 13,027 ~ JUl200B AUG2008 SEP2008 OCT2DDB NOV2QD8 DEC2D08 JAN2DD9 FeB2D09 MAR 2009 APR20C19 MAY 2009 JUN 2009 TOTAL ~ ADM1N1STRATOR $5,552 $5,552 $5,552 $5,552 $5,552 $5,552 $5,552 $5,5$2 $5,552 $5,552 $5,552 $5,552 $66,624 ASST ADMIN I DIRECTORS 5,213 5,213 5,213 5,213 5,213 5,213 9,566 9,566 9,566 9,566 9,566 9,566 88,677 MARKETING 2,904 2,904 2,904 2,904 2,90"1 2,904 2,904 2,904 2,904 2,904 2,904 2,904 34,848 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 CLERICAL 13,773 13,773 13,773 13,175 13,773 13.773 16,$28 16,526 16,528 16,528 16,528 16,528 181,606 FRINGE BENFITS 4,630 4,650 ',630 4,630 ',630 4,630 5,829 5,829 5,829 5,829 5,529 5,629 62,154 REPAIRS llo MAINT, 98 98 98 98 .. 98 .. 98 98 .. 98 .. 1,178 TRANSP I AUTO EXPENSE 3,457 3,457 3,457 3,457 3,457 3.457 3,457 3,457 3,457 3.457 3,457 3,457 41,484 TRAVEL f LODGING I CONFERENCES " " " " " " " " " 93 " " 1,116 COMMUNITY EDUCATION' ADVERTISING '41 '" '41 '" '" '41 '" '" '" '41 '41 '" 8,692 CONTRACTEDSVCS. {CONSULTING 50 " 50 50 50 " 50 50 " 50 50 50 600 DUES & SUBSC~IPTIONS " " " " " " " " 40 " 40 " 460 COMMUNICATION I TELEPHONE 2,374 2,374 2,374 2,314 2,374 2,374 2,374 2,374 2,374 2,314 2,374 2,374 26,468 EQUIPMENT RENT I COMPlfTERS 0 0 0 0 0 0 0 0 0 0 0 0 0 JANITORAL I PLANT OP '50 '50 '50 '50 '50 '50 '50 '50 ,sa '50 '" '50 3.095 LICENSE & TAXES "2 '92 '" '92 '" '" '" '" '92 '" '" '" ',3D< OFFICE SUPPLIES 9SO 9SO 990 9SO 990 990 ..0 ,go 990 '" ..0 990 11,680 POSTAGE & COURIERS '" ,., '" '" 26' 26' "7 26' '" '" 26' '" 3,204 HOME OFFICE ALLOCATION 14,911 14,911 14,911 14,911 14,911 14,911 14,911 14,911 14,911 14,911 14,911 14,911 178,932 eXPENSE CONTINGENCY 0 0 0 0 0 0 0 0 0 0 0 0 0 DEPRECIATION " " " " 23 " " " " " " " '76 AMORTIZATION OF CAPITAL COST 1,167 1,167 1,167 1,167 1,187 1.167 1,167 1,167 1,187 1,167 1,167 1,167 14,004 BUILDING RENTAL '60 765 765 '60 "5 765 765 765 765 760 '65 760 9,1BO UTILITIES ". '" '" '" ". '" '" '" '" '" '" ". 5,110 RESERVED 4,074 4,D74 4,074 4,074 4,074 4,074 4,074 4.074 4,074 4,074 4,074 4,074 4MB7 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 RESERVED 0 0 0 0 0 0 0 0 0 0 0 0 0 - --. ---.- -_. --- - "..-.- --- --.- -- --. -- --- TOTAL OVERHEAD COST 561,998 $61,998 $61,998 5&1,996 $61,998 $61,998 $70,305 $70,305 $70,305 $70,305 $70,305 $70,305 S79M1B --0' --- ...- -- -- -- -- - --- --- -- -- - TOTAL EXPENSE '107,924 $107,924 5107,924 $107,924 $107,924 $107,924 $116,231 $118,231 $116,231 $116,231 $116,231 $116,533 $1,545,232 --- --- --- _m -- --- .-.- - -- --- ..--. --- AVO. COST PER VISIT $99.47 .199.47 $99.47 $99.47 $99.47 $99.47 $107.13 $107.13 S107.13 $107.13 $107.13 $106.72 $103.26 INTREPID NEW AGENCY SSDR 8 SERYJCING CHATTAHOOCHEE, CLAY, HARRIS, MACON, MARION, OUlTMAN, RMDOLPH, SCHLEY, STEWART, SUMTER,TALBOT AND TAYLOR COUNTIES, GEORGIA PROJECTED PRO FORMA INCOME STATEMENT YEAR' WSlT ESTIMATE a: DISCIPlINE SKILLED NURSING PHYSICAL THERAPY SPEECH THERAPY OCCUPATIONAL THERAPY MEDICAL SOCIl\L WORKER HOME HEALTH AIDE MEDICAL SUPPLIES TOTALS MedK:1l1'e Per Plltlent AvgVlslbperPalients ~ SKilLED NURSING PHYSICAL THERAPY SPEECH THERAPY OCCUPATIONAL THERAPY MEDICAL SOCIAL WORKER HOME HEALTH AJOE MEDICAL SUPPLIES TOTAlS BECON.CILlATIONOF COST: TOTAL DIRECT COST FROM FIN STMTS TOTAL A&G COST FROM FIN STMTS HOME OfFICE ALLOCATION TOTAL COST LESS NONALLOWASLE COSTS TOTAL REIMBURSABLE COST 1J,027 TOTAL DIRECT OVERHEAD REIMB. COST MEDICARE MEDICARE COST UMIT MEDICARE MEDICARE CONTRACT. CAP VISITS COST CaST COST PERYlSfT ""'ITS COST PERWSlr COSTUMIT ClMRGes AOJUST. SPACe 6,099 $232.896 $340,856 5573,754 594.07 5,066 $476,576 $92.41 $468,170 $860,$67 3.6B5 214,060 S313,29O 527,349 $14-3.11 3,061 -436.051 $103.54 316,939 583,274 132 5,412 $7,921 13,333 $101.01 ,.. 10,909 $108,18 11,663 20,579 58' 23,947 $35,047 58,89< $99.99 .., 49,295 $105.34 51,933 93,S41 120 4,920 $7,201 12,121 $101.Q1 108 10,909 $143.42 15,490 20,579 2,401 33,670 $49,278 82,948 534.55 1,993 68,852 $38.59 76,912 184,751 21,484 $40,224 87,708 56,240 56,240 45,657 13,027 $542.398 579"'"3:ii8 51.33i.2Oi s~ 1M29 $1,110,631 $997,366 51,a09.7.i9 5812,382 ($113,465) 41,64 60,94 102.57 $102.58 $92.10 No, ^vu PPS .""" - f!Ill -- ." 3,114.25 1,624,478 21.16 3,174.53 1,225,370.00 MEDICAID MEDICAID COST LIMITS MEDICAtD STATeWIDE STATEWlOE MEDICAID CONTRACT, CAP l/IiWi miX em.l'Im ~ AVGRATE AYG REV. ~ &!l!ll m&li '" $32,136 $92.41 32,160 $72.61 $25,266 $59,143 ,,. ~,194 $103.54 21,122 $12.61 14,612 36,812 " 1.212 $108.16 1,298 572.61 871 2,267 3B 3,600 $105.34 3,792 $12.61 2,614 ',S80 , , $143.42 . 572,61 . . 132 4,580 $38.59 5,094 512.61 9,585 12,236 3.863 3,863 3,136 732 575,167 63,467 $67,014 $122.534 $69,067 (16,153) 102.89 n89 REIMBURSABLE ~SU~ ~ JlAIlQ = MEDICARE: $45,857 0,_ $6,240 MEDICAID 3,136 0.0571 3,863 INSlPRIVATE 4,551 0,0B21l 5,'" INDIGENT 1,622 0.0295 1,998 - - TOTAL S54,B67 $87,708 $551,414 614,886 1ZD.m $1,345,232 2 $1,345,232 APPENDIX G ,I II I' II II ~ I I 'I Ii II I I I I I I , I II II I I: I I Georgia UUA Payor Data 10-20-06. Ga DCH HHA Survey (unedited data). 1/6 Georgia HHA Payor Data, SSDR 8 Providers, 2003-2005 Yearl Total Tolal Grs Pal Net Pat Vis! GPR$! GPR$! %Tolal %Tolal %Total %Total Payor Patienls Visits Revenue Revenue Pat. Pat. Visit Pat's Visits GPR$ NPR$ 2003 Statewide HHA Provider Summary Medicare 78,332 1,935,064 256,532,040 242,999,542 24.7 3,275 132.57 66.5 78.8 80.4 87.5 Medicaid 12,372 200,660 21,514,693 11,316,603 16.2 1,739 107.22 10.5 8.2 6.7 4.1 Other Govt 893. 15,319 1,390,843 927,647 17.2 1,557 90.79 0.8 0.6 0.4 0.3 Mgd Ca re 8,289 91,818 12,766,786 4,741,888 11.1 1,540 139.04 7.0 3.7 4.0 1.7 3rd Party 11,981 140,648 18,173,513 12,584,263 11.7 1,517 129.21 10.2 5.7 5.7 4.5 Self Pay 1,685 28,929 2,889,332 1,298,906 17.2 1,715 99,88 1.4 1.2 0.9 0,5 Non-Govt 4,224 42,438 5,901,309 3,797,788 10,1 1,397 139.06 3.6 1.7 1,9 1.4 TOTAL 117,776 2,454,876 319,168,516 277,666,637 20.8 2,710 130,01 100.0 100.0 100,0 100,0 2004 Statewide HHA Provider Summary Medicare 80,236 1,930,699 268,149,202 257,396,091 24.1 3,342 138,89 69.4 82.3 83.6 89.6 Medicaid 10,582 151,887 17,266,167 8,088,825 14.4 1,632 113,68 9.2 6.5 5.4 2.8 Other Govt 1,238 14,241 1,306,626 880,790 11.5 1,055 91.75 1.1 0,6 0.4 0.3 Mgd Care 7,407 96,034 11,033,160 7,654,253 13.0 1,490 114.89 6.4 4.1 3.4 2.7 3rd Party 13,554 127,562 19,422,549 12,561,791 9.4 1,433 152.26 11,7 5.4 6.1 4.4 Self Pay 1,219 13,899 1,592,775 206,354 11.4 1,307 114.60 1,1 0,6 0.5 0.1 Non-Govt 1,368 10,679 1,835,657 529,926 7.8 1,342 171.89 1,2 0,5 0.6 0.2 TOTAL 115,604 2,345,001 320,606,136 287,318,030 20.3 2,773 136,72 100,0 100,0 100.0 100.0 2005 Statewide HHA Provider Summary Medicare 85,649 2,043,913 301,166,190 292,657,516 23.9 3,516 147.35 69.2 81.2 84.6 90.2 Medicaid 9,838 160,571 17,376,278 8,265,897 16.3 1,766 108.22 8.0 6.4 4.9 2.6 Other Govt 789 15,749 1,592,922 991,754 20.0 2,019 101.14 0.6 0.6 0.5 0.3 Mgd Care 11,841 118,133 14,438,165 9,839,203 10.0 1,219 122.22 9.6 4.7 4,1 3.0 3rd Party 12,070 143,159 17,332,817 12,352,920 11,9 1,436 121.07 9.8 5.7 4.9 3.8 Self Pay 1,179 23,610 1,737,765 109,298 20,0 1,474 73.60 1.0 0.9 0,5 0,0 Non-Govt 2,447 12,117 2,432,680 276,142 5,0 994 200.77 2.0 0.5 0,7 0.1 TOTAL 123,813 2,517,252 356,076,817 324,492,730 20.3 2,876 141.45 100.0 100.0 1000 100,0 2003 SSDR 8 HHA Provider Summary Medicare 4,134 85,860 10,739,010 11,215,216 20,8 2,598 125.08 73.7 81.3 79,9 87.8 Medicaid 662 10,076 1,251,647 535,754 15.2 1,891 124,22 11.8 9.5 9.3 4,2 Other Govt 55 651 10,895 7,710 11.8 198 16.74 1.0 0.6 0.1 0.1 Mgd Care 4 57 7,890 5,959 14.3 1,973 138.42 0.1 0.1 0.1 0.1 3rd Party 661 8,071 1,312,971 936,066 12.2 1,986 162,68 11.8 7.6 9.8 7,3 Self Pay 17 338 17,408 31,281 19.9 1,024 51.50 0.3 0.3 0.1 0.2 Non-Govt 80 593 93,332 37,688 7.4 1,167 157,39 1.4 0,6 0.7 0,3 TOTAL 5,613 105,646 13,433,153 12,769,674 18.8 2,393 127,15 100.0 100.0 100.0 100.0 2004 SSDR 8 HHA Provider Summary Medicare 3,963 82,470 12,543,894 11,556,684 20.8 3,165 152.10 72.5 82,0 84.1 90.3 Medicaid 532 7,162 874,995 322,984 13.5 1,645 122,17 9.7 7.1 5.9 2.5 Other Govt 78 1,213 66,872 50,560 15.6 857 55.13 1.4 1.2 0.5 0.4 Mgd Care 251 2,723 420,176 242,349 10.9 1,674 154.31 4,6 2,7 2.8 1.9 3rd Party 609 6,668 984,259 627,417 11.0 1,616 147.61 11.1 6.6 6.6 4.9 Self Pay 18 108 9,517 (4,944) 6.0 529 88.12 0.3 0.1 0.1 0.0 Non-Govt 19 180 8,770 0 9.5 462 48.72 0.4 0.2 0.1 0.0 TOTAL 5,470 100,524 14,908,483 12,795,050 18.4 2,725 148,31 100.0 100.0 100.0 100.0 2005 SSDR 8 HHA Provider Summary 10-20-06. Ga DCH HHA Survey (unedited data). 2/6 Georgia HHA Payor Data, SSDR 8 Providers, 2003-2005 Year/ Total Total Grs Pat Net Pat Vis/ GPR$/ GPR$/ %Total %Total %Total %Total Payor Patients Visits Revenue Revenue Pat. Pat. Visit Pat's Visits GPR$ NPR$ Medicare 4,406 93,217 13,800,540 13,275,456 21.2 3,132 148.05 72.9 83.0 86.9 91.3 Medicaid 406 6,324 623,281 279,931 15.6 1,535 98.56 6.7 5.6 3.9 1.9 Other Govt 109 1,985 19,921 8,553 18.2 183 10.04 1.8 1.8 0.1 0.1 Mgd Care 16 164 20,392 20,392 10.3 1,275 124.34 0.3 0.2 0.1 0.1 3rd Party 1,058 10,173 1,313,422 961 ,493 9.6 1,241 129.11 17,5 9,1 8.3 6.6 Self Pay 24 148 21,534 (976) 6.2 897 145.50 0.4 0.1 0.1 0,0 Non-Govt 29 240 77,484 0 8.3 2,672 322.85 0.5 0,2 0.5 0.0 TOTAL 6,048 112,251 15,876,574 14,544,849 18.6 2,625 141.44 100.0 100,0 100.0 100.0 2003 Access Home Health (cis) (MuscogeeISSDR8IHHA134) Medicare 89 1,186 195,778 178,680 13.3 2,200 165.07 90.8 95.9 97.0 114.5 Medicaid 0 0 0 0 0.0 0.0 0,0 0.0 Other Govt 0 0 0 0 0.0 0.0 0,0 0,0 Mgd Care 0 0 0 0 0.0 0.0 0,0 00 3rd Party 9 51 6,090 3,994 5.7 677 119.41 9.2 4.1 3.0 2,6 Self Pay 0 0 0 0 0.0 0.0 0,0 0,0 Non-Govt 0 0 0 (26,575) 0.0 0.0 0.0 -17,0 TOTAL 98 1,237 201,868 156,099 12,6 2,060 163.19 100.0 100.0 100,0 100,0 2004 Access Home Health (cis) (Muscogee/SSDR8/HHA134) Medicare 243 3,636 1,041,859 571,382 15.0 4,287 286.54 91.4 92.5 96.8 96,6 Medicaid 0 0 0 0 0.0 0.0 0.0 0,0 Other Govt 0 0 0 0 0.0 0.0 0.0 0,0 Mgd Ca re 0 0 0 0 0.0 0.0 0.0 00 3rd Party 20 265 34,355 20,388 13,3 1,718 129,64 7.5 6.7 3.2 3,5 Self Pay 3 32 0 0 10.7 0 0.00 1.1 0.8 0.0 0,0 Non-Govt 0 0 0 0 0.0 0.0 0.0 0,0 TOTAL 266 3,933 1,076,214 591,770 14.8 4,046 273.64 100.0 100.0 100.0 100,0 2005 Access Home Health (cis) (Muscogee/SSDR8/HHA134) Medicare 159 2,630 314,401 441,210 16.5 1,977 11954 82.8 90.3 90.2 95.1 Medicaid 7 85 10,386 5,450 12.1 1,484 122,19 3.7 2.9 3.0 1.2 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 26 199 23,602 17.450 7.7 908 118,60 13.5 6.8 6.8 3.8 Self Pay 0 0 0 0 0.0 0.0 0.0 0.0 Non-Govl 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 192 2,914 348,389 464,110 15.2 1,815 119,56 100.0 100.0 100.0 100.0 2003 CareSouth Cordele/Crisp Hasp (Crisp/SSDR8/HHA052) Medicare 245 4,840 810,025 710,207 19.8 3,306 167,36 54.6 58.5 67.9 78.3 Medicaid 159 2,940 304,408 132,109 18.5 1,915 10354 35.4 35.5 25.5 14,6 Other Gavt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 0 0 0 0 0.0 0.0 0.0 0,0 Self Pay 0 0 0 0 0.0 0.0 0.0 0.0 Non-Govt 45 501 78,302 64,263 11.1 1,740 156.29 10.0 6.1 6.6 7.1 TOTAL 449 8,281 1,192,735 906,579 18.4 2,656 144,03 100.0 100.0 100.0 100.0 2004 CareSauth Cordele/Crisp Hasp (Crisp/SSDR8/HHA052) Medicare 226 5,423 799,936 773,966 24.0 3,540 147,51 61.9 66.6 74.7 82.6 Medicaid 72 1,865 152,610 68,365 25.9 2,120 81.83 19.7 22.9 14.3 7.3 10-20-06. Ga DCH HHA Survey (unedited data). 3/6 Georgia HHA Payor Data, SSDR 8 Providers, 2003-2005 Yearl Total Total Grs Pat Net Pat Visl GPR$I GPR$! %Total %Total %Total %Total Payor Patients Visits Revenue Revenue Pat. Pat. Visit Pat's Visits GPR$ NPR$ Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 62 837 117.914 100.594 13.5 1,902 140.88 17.0 10.3 11.0 10.7 Self Pay 1 1 152 (5.395) 1.0 152 152.00 0.3 0.0 0.0 -0.6 Non-Govt 4 23 685 0 5.8 171 29.78 1.1 0.3 0.1 0.0 TOTAL 365 8,149 1,071.297 937.530 22.3 2.935 131.46 100.0 100.0 100.0 100.0 2005 CareSouth Cordele/Crisp Hosp (Crisp/SSDR8/HHA052) Medicare 315 7.969 1,092,664 1,095.987 25.3 3,469 137.11 73.4 77.5 87.5 90.5 Medicaid 66 1,630 65,830 52,614 24.7 997 40.39 15.4 15.9 5.3 4.4 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 00 0.0 0.0 0.0 3rd Party 42 605 79,674 61,534 14.4 1,897 131.69 9.8 5.9 6.4 5.1 Self Pay 4 48 7,120 687 12.0 1,780 148.33 0.9 0.5 0.6 0.1 Non-Govt 2 26 3,640 0 13.0 1,820 140.00 0.5 0.3 0.3 0.0 TOTAL 429 10,278 1,248,928 1,210,822 24.0 2,911 121.51 100.0 100.0 100.0 100.0 2003 Caresouth Muscogee (Muscogee/SSDR8/HHA053) Medicare 1,550 20,586 3,148,148 2,953,575 13.3 2.031 152.93 90.6 91.8 90.6 .93.3 Medicaid 57 529 96,932 22,906 9.3 1,701 183.24 3.3 2.4 2.8 0.7 other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 69 1,216 216,326 163.352 17.6 3,135 177.90 4.0 5.4 6.2 5.2 Self Pay 0 0 0 25,822 0.0 0.0 0.0 0.8 Non-Govt 35 92 15,030 0 2.6 429 163.37 2.1 0.4 0.4 0.0 TOTAL 1,711 22,423 3,476,436 3,165,655 13.1 2,032 155.04 100.0 100.0 100.0 100.0 2004 Caresouth Muscogee (Muscogee/SSDR8/HHA053) Medicare 1.276 22.953 3.709,350 3.386,911 18.0 2,907 161.61 88.0 90.8 94.0 96.5 Medicaid 77 1,083 95,083 41,348 14.1 1,235 87.80 5.3 4.3 2.4 1.2 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 00 0.0 3rd Party 81 1,080 133,047 82,618 13.3 1,643 123.19 5.6 4.3 3.4 2.4 Self Pay 1 1 0 0 1.0 0 0.00 0.1 0.0 0.0 0.0 Non-Govt 15 157 8,085 0 10.5 539 51.50 1.0 0.6 0.2 0.0 TOTAL 1,450 25,274 3,945,565 3,510,877 17.4 2,721 156.11 100.0 100.0 100.0 1000 2005 Caresouth Muscogee (Muscogee/SSDR8/HHA053) Medicare 1,641 31,026 4,778,094 4,736,533 18.9 2,912 154.00 84.9 89.4 91.1 93.6 Medicaid 105 1,520 81,822 57,724 14.5 779 53.83 5.4 4.4 1.6 1.1 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 159 1,933 323,632 274,434 12.2 2.035 167.42 8.2 5.6 6.2 5.4 Self Pay 2 3 532 (10,251) 1.5 266 177.33 0.1 0.0 0.0 -0.2 Non-Govt 27 214 61,378 0 7.9 2,273 286.81 1.4 0.6 1.2 0.0 TOTAL 1,934 34,696 5,245,458 5,058,440 17.9 2,712 151.18 100.0 100.0 100.0 100.0 2003 Chatlahoochee Valley HH (Muscogee/SSDR8/HHA019) Medicare 892 19,805 2,663,891 3,509,737 22.2 2,986 134.51 58.0 70.2 67.9 81.8 Medicaid 216 3.117 449,129 229,016 14.4 2,079 144.09 14.0 11.1 11.5 5.3 Other Govt 53 600 4,520 3,120 11.3 85 7.53 3.4 2.1 0.1 0.1 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 10-20-06, Ga DCH HHA Survey (unedited data), 4/6 Georgia HHA Payor Data, SSDR 8 Providers, 2003-2005 Yearl Total Total Grs Pat Net Pat Vis/ GPR$/ GPR$I %Total %Total %Total %Total Payor Patients Visits Revenue Revenue Pat. Pat. Visit Pat's Visits GPR$ NPR$ 3rd Party 372 4,537 800,422 549,342 12.2 2,152 176.42 24.2 16,1 20.4 12.8 Self Pay 6 141 3,942 2,192 23,5 657 27.96 0.4 0,5 0.1 0,1 Non-Govt 0 0 0 0 0.0 0,0 0,0 0,0 TOTAL 1,539 28,200 3,921,904 4,293,407 18,3 2,548 139.07 100,0 100,0 100,0 100,0 2004 Chattahoochee Valley HH (Muscogee/SSDR8/HHA019) Medicare 915 19,186 2,589,775 2,534,312 21,0 2,830 134.98 54.2 69,8 67.4 79,7 Medicaid 215 2,472 391,856 142,270 11,5 1,823 158.52 12,7 9.0 10,2 4.5 Other Govt 76 1,162 60,497 45,970 15,3 796 52.06 4.5 4.2 1,6 1.5 Mgd Care 249 2,677 414,426 237,979 10,8 1,664 154.81 14,8 9,7 10.8 7,5 3rd Party 229 1,996 382,682 219,673 8.7 1,671 191,72 13,6 7.3 10,0 6,9 Self Pay 3 5 740 451 1.7 247 148,00 0.2 0,0 0,0 0.0 Non-Govt 0 0 0 0 0,0 0.0 0,0 0,0 TOTAL 1,687 27,498 3,839,976 3,180,655 16,3 2,276 139,65 100,0 100,0 100,0 100.0 2005 Chattahoochee Valley HH (Muscogee/SSDR8/HHA019) Medicare 782 16,264 2,181,201 2,321,639 20,8 2,789 134.11 52,8 66,0 71.8 82,7 Medicaid 155 2,055 338,603 117,933 13.3 2,185 164,77 10.5 8,3 11,1 4.2 Other Govt 97 1,889 8,025 5,147 19,5 83 4.25 6,6 7,7 0.3 0.2 Mgd Care 0 0 0 0 0.0 0,0 0,0 0,0 3rd Party 442 4,395 508,293 361,105 9,9 1,150 115.65 29,8 17,8 16,7 12,9 Self Pay 6 27 3,932 2,588 4,5 655 145,63 0.4 0,1 0,1 0,1 Non-Govt 0 0 0 0 0.0 0,0 0,0 0,0 TOTAL 1,482 24,630 3,040,054 2,808,412 16,6 2,051 123.43 100.0 100,0 100.0 100,0 2003 Lanier Home Health (Harris/SSDR8/HHA 113) Medicare 51 851 78,528 87,121 16,7 1,540 92.28 83,6 88,1 86,5 88,8 Medicaid 0 0 0 0 0.0 0.0 0,0 0,0 Other Govt 0 0 0 0 0,0 0,0 0.0 0,0 Mgd Care 0 0 0 0 0.0 0,0 0.0 0.0 3rd Party 10 115 12,282 10,953 11,5 1,228 106,80 16.4 11,9 13.5 11,2 Self Pay 0 0 0 0 0,0 0,0 0.0 0.0 Non-Govt 0 0 0 0 00 0,0 0,0 0.0 TOTAL 61 966 90,810 98,074 15.8 1,489 94,01 100,0 100,0 100.0 100,0 2004 Lanier Home Health (HarrislSSDR8/HHA 113) Medicare 42 793 63,848 70,108 18,9 1,520 80,51 84.0 94,6 91,8 93.8 Medicaid 0 0 0 0 0,0 00 0,0 0,0 Other Govt 0 0 0 0 0,0 0,0 0,0 0,0 Mgd Care 0 0 0 0 0.0 0,0 0,0 0,0 3rd Party 8 45 5,707 4,664 5.6 713 126.82 16,0 5.4 8,2 6,2 Self Pay 0 0 0 0 0,0 0,0 0.0 0,0 Non-Govt 0 0 0 0 0.0 0,0 0,0 0.0 TOTAL 50 838 69,555 74,772 16.8 1,391 83,00 100,0 100.0 100,0 100,0 2005 Lanier Home Health (Harris/SSDR8/HHA113) Medicare 63 1,119 100,451 115,519 17,8 1,594 89.77 88,7 92,9 92,6 95,2 Medicaid 0 0 0 0 0.0 0.0 0,0 0,0 Other Govt 1 12 1,396 1,186 12,0 1,396 116,33 1.4 1,0 1.3 1,0 M9d Care 0 0 0 0 0.0 0,0 0.0 0,0 3rd Party 7 73 6,668 4,668 10.4 953 91,34 9.9 6.1 6,1 3,9 Self Pay 0 0 0 0 0,0 0.0 0.0 0,0 10-20-06. Ga DCH HHA Survey (unedited data). 5/6 Georgia HHA Payor Data, SSDR 8 Providers, 2003-2005 Year/ Total Total Grs Pat Net Pat Vis/ GPR$/ GPR$/ %Total %Total %Total %Total Payor Patients Visits Revenue Revenue Pat. Pat. Visit Pat's Visits GPR$ NPR$ Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 71 1,204 108,515 121,373 17.0 1,528 90.13 100.0 100.0 100.0 100.0 2003 Muscogee Home Health Agency (Muscogee/SSDR8/HHA116) Medicare 140 3,708 463,500 396,756 26.5 3,311 125.00 92.1 94.5 94.5 95.8 Medicaid 5 100 12,500 7,000 20.0 2,500 125.00 3.3 2.6 2.6 1.7 Other Govt 2 51 6,375 4,590 25.5 3,188 125.00 1.3 1.3 1.3 1.1 Mgd Care 4 33 4,125 3,135 8.3 1,031 125.00 2.6 0.8 0.8 0.8 3rd Party 1 30 3,750 2,850 30.0 3,750 125.00 0.7 0.8 0.8 0.7 Self Pay 0 0 0 0 0.0 0.0 0.0 0.0 Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 152 3,922 490,250 414,331 25.8 3,225 125.00 100.0 100.0 100.0 100.0 2004 Muscogee Home Health Agency (Muscogee/SSDR8/HHA116) Medicare 170 3,841 480,125 403,305 22.6 2,824 125.00 91.4 91.2 91.2 92.9 Medicaid 9 120 15,000 7,200 13.3 1,667 125.00 4.8 2.9 2.9 1.7 Other Govt 2 51 6,375 4,590 25.5 3,188 125.00 1.1 1.2 1.2 1.1 Mgd Care 2 46 5,750 4,370 23.0 2,875 125.00 1.1 1.1 1.1 1.0 3rd Party 3 153 19,125 14,535 51.0 6,375 125.00 1.6 3.6 3.6 3.4 Self Pay 0 0 0 0 0.0 0.0 0.0 0.0 Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 186 4,211 526,375 434,000 22.6 2,830 125.00 100.0 100.0 100.0 100.0 2005 Muscogee Home Health Agency (Muscogee/SSDR8/HHA116) Medicare 118 3,491 436,375 411,938 29.6 3,698 125.00 88.7 94.2 91.8 96.6 Medicaid 6 76 9,500 5,974 12.7 1,583 125.00 4.5 2.1 2.0 1.4 Other Govt 1 84 10,500 2,220 84.0 10,500 125.00 0.8 2.3 2.2 0.5 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 4 10 1,250 611 2.5 313 125.00 3.0 0.3 0.3 0.1 Self Pay 4 44 5,500 5,500 11.0 1,375 125.00 3.0 1.2 1.2 1.3 Non-Govt 0 0 12,466 0 0.0 0.0 2.6 0.0 TOTAL 133 3,705 475,591 426,243 27.9 3,576 128.36 100.0 100.0 100.0 100.0 2003 Ultra Care Georgia (Muscogee/SSDR8/HHA133) Medicare 0 805 8,584 8,584 10.66 94.6 69.5 75.3 Medicaid 0 22 0 0 0.00 2.6 00 00 Other Govt 0 0 0 0 0.0 0.0 0.0 Mgd Care 0 24 3,765 2,824 156.88 2.8 30.5 24.8 3rd Party 0 0 0 0 0.0 0.0 0.0 Self Pay 0 0 0 0 0.0 0.0 0.0 Non-Govt 0 0 0 0 0.0 0.0 0.0 TOTAL 0 851 12,349 11,408 14.51 100.0 1000 100.0 2004 Ultra Care Georgia (Muscogee/SSDR8/HHA133) Medicare 0 0 0 0 Medicaid 0 0 0 0 Other Govt 0 0 0 0 Mgd Care 0 0 0 0 3rd Party 0 0 0 0 Self Pay 0 0 0 0 Non-Govt 0 0 0 0 TOTAL 0 0 0 0 10-20-06. Ga DCH HHA Survey (unedited data). 6/6 Georgia HHA Payor Dala, SSDR 8 Providers, 2003-2005 Yearl Tolal Total Grs Pal NelPal Visl GPR$I GPR$I "/oTolal "/oTolal "/oTotal "/oTolal Payor Patients Visits Raven ue Revenue Pat. Pat. Visit Pat's Visits GPR$ NPR$ 2005 Ullra Care Georgia (Muscogee/SSDR8/HHA133) Medicare 330 5,676 813,675 813,675 17.2 2,466 143.35 91.9 95.1 95.7 95.7 Medicaid 0 0 0 0 0.0 0.0 0.0 0.0 Other Govt 10 0 0 0 0.0 0 2.8 0.0 0.0 0.0 Mgd Care 7 0 0 0 0.0 0 2.0 0.0 0.0 0.0 3rd Party 12 293 36,609 36,609 24.4 3,051 124.95 3.3 4.9 4.3 4.3 Self Pay 0 0 0 0 0.0 0.0 0.0 0.0 Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 359 5,969 850,284 850,284 16.6 2,368 142.45 100.0 100.0 100.0 100.0 2003 VNA Cordele (Crisp/SSDR8/HHA067) Medicare 1,167 34,079 3,370,556 3,370,556 29.2 2,888 98.90 72.8 85.7 83.3 90.5 Medicaid 225 3,368 388,678 144,723 15.0 1,727 115.40 14.0 8.5 9.6 3.9 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 200 2,122 274,101 205,575 10.6 1,371 129.17 12.5 5.3 6.8 5.5 Self Pay 11 197 13,466 3,267 17.9 1,224 68.36 0.7 0.5 0.3 0.1 Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 1,603 39,766 4,046,801 3,724,121 24.8 2,525 101.77 100.0 100.0 100.0 100.0 2004 VNA Cordele (Crisp/SSDR8/HHA067) Medicare 1,091 26,638 3,859,001 3,816,700 24.4 3,537 144.87 74.4 87.0 88.1 93.9 Medicaid 159 1.622 220,446 63,801 10.2 1,386 135.91 10.9 5.3 5.0 1.6 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 0 0 0 0 0.0 0.0 0.0 0.0 3rd Party 206 2,292 291,429 184,945 11.1 1,415 127.15 14.1 7.5 6.7 4.6 Self Pay 10 69 8,625 0 6.9 863 125.00 0.7 0.2 0.2 0.0 Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 1,466 30,621 4.379,501 4,065,446 20.9 2,987 143.02 100.0 100.0 100.0 100.0 2005 VNA Cordele (Crisp/SSDR8/HHA067) Medicare 998 25,042 4.083,679 3,338,955 25.1 4,092 163.07 68.9 86.8 89.6 92.6 Medicaid 67 958 117.140 40,236 14.3 1.748 122.28 4.6 3.3 2.6 1.1 Other Govt 0 0 0 0 0.0 0.0 0.0 0.0 Mgd Care 9 164 20,392 20,392 18.2 2,266 124.34 0.6 0.6 0.5 0.6 3rd Party 366 2,665 333,694 205,082 7.3 912 125.21 25.3 9.2 7.3 5.7 Self Pay 8 26 4,450 500 3.3 556 171.15 0.6 0.1 0.1 0.0 Non-Govt 0 0 0 0 0.0 0.0 0.0 0.0 TOTAL 1.448 28,855 4,559,355 3,605,165 19.9 3,149 158.01 100.0 100.0 1000 100.0 APPENDIX G Intrepid Payor Mix Data, GA HHAs, 2005 Patient Origin by Planning Area By Payer Type 2005 State Service Delivery Regions See selection criteria at end of report; totals for each area are in area header Other Managed Third Non Total Medicaid Medicare Government Care Party Self Pay Government Patients By County Patients Patients Patients Patients Patients Patients Patients Payer Type 2005 283 1,019 25 0 232 4 0 1,563 Area 10 226 452 1 0 74 1 0 754 Dougherty 226 452 1 0 74 1 0 754 Intrepid USA Healthcare Services H HAOO 1 226 452 1 0 74 1 0 754 Area 11 16 172 20 0 80 2 0 290 Lowndes 16 172 20 0 80 2 0 290 Intrepid USA Healthcare Services HHA011 16 172 20 0 80 2 0 290 Area 12 41 395 4 0 78 1 0 519 Glynn 41 395 4 0 78 1 0 519 Intrepid USA Healthcare Services H HA004 41 395 4 0 78 1 0 519 Source: Home Health Survey Prepared By: Department of Community Health Notes: The report totals and subtotals include only those records specified in selection criteria, if any, shown below. If no criteria are shown, all records are included. ([Year] >= '2005'AND [Year] <=='2005' AND [UID] in('HHA001', 'HHAOQ4', 'HHA011 ') ) Wednesday, October 18, 2006 Page 10f1 "1 APPENDIX H Supplemental Effects on Payors Documentation None Provided i: Ii I " 1: II 'I Ii Ii II ii !i II I il I' Ii Ii ,I 'I 'I I, II 'I II I ~ I Ii II I, I ~ I: I ,I Ii II " Ii I' ]! II Ii I' it I! " II I, Ii II I I Ii Ii Ii 1i II " ji I' I' I, " I' I' .I I, I, APPENDIX I Architectural Documentation Not Applicahle (\ APPENDIX J II I: Ii !I Ii j~ i , I: II I! I, II II II " II II " I' ,I I I ,I II Ii I' " I, Ii I' , :1 I, I I I II I: I, 'I II ,I II " II " I 'I II I' ,I ,I II 'I ], II i ~ " II II Ii I II I' I' ,I II II 'I II j! II I: .I Ii I I, II Indigent Care Policy ( \ . Intrepid USA Healthcare Services Policy and Procedure 11::l()li<:Yf>llllllt;!:.1 ngigellt .IGhCirityGare- Ge()rg iCi I Section: . 2 I.Gllrt;![)t;!li"erY 1::l()licyNullll:lt;!r: 2.888 GA Effective Date: ... ()ctober12, 200~ Revision Date: Policy Statement: To define the processes and required approvals necessary to engage in the provision of services to indigent clients. The agency will provide care to all clients regardless of the client's ability to pay, as allowed by agency resources. Indigent care is defined as all unpaid charges for services to clients whose family income level was equal to or less than one-hundred-fifty (150) percent of Federal Poverty Guidelines, excluding those unpaid charges classified as contractual allowances for Medicare or other free care such as courtesy allowances, policy discounts, and administrative adjustments. Guidelines I Procedures: 1. Clients who are unable to pay for services are accepted for care under certain conditions. 2. If there is no third-party source for reimbursement of services, the client (or his/her guarantor) is responsible for payment. 3. Cases arise whereby the client or guarantor is financially unable to pay for service due to income. The ability to provide funding to those clients who do not have the means to pay is limited to the amount designated for that purpose by the agency. 4. The Referral/Intake staff obtain and verify insurance and financial information from the client or referring party. Staff verifies insurance coverage. 5. If a client is determined to have no third party payor source and the client is unable to pay for home health services, the Intake nurse will consult with the Administrator and/or the Director of Professional Services, and the Social Worker to determine and document the financial condition of the client. 6. Based on the documented financial information and other pertinent documentation of the client's conditions and needs, after consultation with the physician, and with the approval of the Administrator, the home care plan will be established 7. Medical Social Workers may also evaluate and document the financial condition of the client when Medicare B Outpatient and/or private insurance payor sources do not cover the total cost of services, and outstanding balances are anticipated, and when possible, will assist the client in identifying alternate funding sources. 8. It is anticipated that some clients will exhaust their benefits from their payment source prior to the time when home heaith care is no longer needed. The Medical Social Worker will help these clients to secure an alternative payment source, if available. If no alternative is available, these clients will be reclassified as indigent/charity, as appropriate. It will be the policy of the Company to continue to provide services to these clients as long as care is warranted. Intrepid USA Healthcare Services Indigent / Charity Care - Georgia Page 1 of 2 Policy 2.888GA Intrepid USA Healthcare Services Policy and Procedure g. In addition to the agency criteria for admission, which address appropriateness of home health care and staff safety, the following guidelines are applied when providing uncompensated care to clients: a. The client and/or family accept the program of care in the home and agree to learn to independently manage health care needs. b. The client/family provides all supplies and pharmaceuticals necessary to manage heaith care needs. c. The agency will not accept clients who require two (2) or more visits per day without appropriate compensation from the discharging institution. The Director of Client Care and Administrator negotiates this on a case-by-case basis. d. Referrals to the agency for uncompensated care must include a Social Work referral. e. Cases accepted outside of the above guidelines must be approved in advance by the Director of Client Care, or the agency Administrator. 10. If the agency is unable to admit the client or to continue to deliver service, every effort will be made to refer the client to an appropriate institution, state, local, or county agency for needed care. Intrepid USA Healthcare Services Indigent / Charity Care - Georgia Page 2 of 2 Policy 2.888GA II Ii I ~ I' Ii II 11 i APPENDIX K I, I I Supplemental Documeutation re: Relationship to Health Care Delh:ery System I, None Provided I' II II I' II ,) I II il II ii 11 I: II II II Ii Ii Ii :~ . I Supplemental Docnmentation re: Efficient Utilization, Non-Resid.ent Services, Research Projects, Assistance to Health Professions Programs, Improvements and Innovation, and Needs of HMOs APPENDIX L Either none provided or not applicable APPENDIX M Letters of Support i T 'l<H O. .9ljayi, !Jv(.tJJ. 'f<pane!j 1C SiaUt !FiJI[p.c Soutfi(jeorglf 'Urofog!j CCinu. 803 N. Jackson street. Albany, G~orgia . (229) 435-0832 !, i Suzanne Ryan, RN, Administrator : Intrepid USA Home Health Care 1901 Palmyra Rd. .~ Albany, GA 31701 . , I , Dear Suzanne, ,. , I: i I understand that Intrepid USA has applied to open a Medicare certified home , , health agency in SSDR 8. . I , .. r I .In addition to patients in the Albany area, many of my patients live in the counties ! located in SSDR 8. I currently use Intrepid USA for the patients in yoUr current . service area and am very pleased with the quality of care they receiv~. I would use your new agency without hesitation and feel it w6uld provide an i8creased ; continuity of care for my home care patients. I , I fully support your efforts to obtain the new CON. Sincerely, \ I SmlOU. SlmERI COMfllTS, AU 202 E. Main 51. POBox 119 BRONWOOD, GA 39826 .' Phone 229-995-Mll . Fax 229-995-4045 October 30, 2006 Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. .' Sincerely, '~;/ x1~ ~ Priscilla Seymour Administrator " -lj ,.,; 'it ,'I' ':c' ".'. d.';[ .... : .....,._..., '~ il ,jl"- " ,)1, 'Health Care Center ,) . " ( ';'." "I~ .' "il y., ; . ,; '!i :j "'" ,f . I' 'fi 11 ",", , ,,;(' j. r- '. ,~lo , ,;1 ,. '" ~; ;' yo. ,;! I ,',' ':Suzanne Ryan, RN,Adrninistrator ,iilntrepid USA Horile Health Care :;1901 Palmyra Rd. ' !Albany,GA3,1701' ,. 1~ ' ir' , ' ,iOearSuzanne, . . '.'I .. ""., ii ,'c,,', ' " ' , : . ,',"', '. ~ '" . . " , ' ',_ ,":-, :~ ',',A ,\'. . 'il understand that Intrepid USA has applied to open a Mecjicare certified-home t', '-" .- ',' ' . '. -', ", ',., "1'., ':~f3alth agency in SSDR.8. '. i I, ' ~ Ii it': ;: '. )n 'addition to patients in tile Albaflyarea,manyofmypatientsliVf3in tnec6unties -"Iocatedin SSOR 8.1 currently use Intrepid USA forthe patients in your current' '. . ,service area and am very pleased with the quality of care theyreceiv8.lwolild. ';use 'your new agency without hesitation and feel it w6uldprovide ani~creasecj .:c?~tinuityofcaref9rmYhOmecarepatients.' . d ,.'- ". ii" , ..... "j'.- ' .' -~, , .". . . ,..':' fully support YOlJreffortsWobtain the new CON. '. :;SincereIY, , . l.!A.... ~d-w?~. '~ .,.f;-(... ,........ ,OJ '", I -,1', !:ji " ',:, \.' . Uv~4 'Ji, j:, , i' ): .il , " , " ',',' ,"< i,,' . ii' ~i! . .' ~~' , ., " , Ii ',j .I '. ,. 1", " . .; } 'r "j " , . ~ i;' r. .1 :1 " ';1" L; (, :i .- Y. ....!i '.,. ., . " - ~.l 'I' '.i J 1159 'Georgi~Avenue . P.O. Box 607. Dawson, Georgia 39842. Phone: 229-!)9S-S016fFAx: 229~99S-3272 . ,!'-,"', ,,;, ,",', . ",. '. ". " '.'. ," ". ,'i ' '. ., "..' . 1; 'I .1 'f ~ . ~~ Ii' i," ,i ,.-~, T 1f " " " ,I ,I I . Medical Associates'of Alban~, P.C. JI 11 " Ii " i! II II Ii II ;i Jl I! Ii Ii , " ,I: Suzanne Ryan, RN, Administrator I! Intrepid USA Home Health Care 'I 1901 Palmyra Rd, . " '! Albany, GA 31701 i. .t, - I :i Dear Suzanne, J . , v . { I understand that Intrepid USA has applied to open a Medicare certifi~d home :t health agency in SSDR 8, . I: ,.. 1 , , . " II -: In addition to patients in the Albany area, many of my patients live in :the counties i located in SSDR 8, I currently use Intrepid USA for the patients in yd'ur cement :! service area and am very pieased with the quality of care they receiv:~, I would j use your new agency without hesitation and feel it would provide an increased l continuity of care for my home care patients, I: ' I l; '."1. il 1 I fully support your efforts to obtain,the new CON, . ., ;~~ ,i ,Michael Raines, M,D. :i, Medical Associates of Albany :;, ,I ii, i :1 " :~ . 11 ,I a :1' :1 I. ~r 'I I' i! .i ,t 'I 'j " " Ii II ,. j.' ., 1 " Ii 'I i, ji i: I! , ii j! Ii Ii , 1\ ': " l. 11 :i INTERNAT MF.m~TNF. Charles F. Gcbha,f:dt, M.D. . Sterling 1. Barrett. M.D. . Devell R. Young, M.D. Palrnyrn Parl:. Physicinns Center. 2002 Palmyra Road Suite 101 '; Albany, GA 31701' (229) 432-]440 . FAMII Y'PRACTICE Thomas A. Hilsman, M.D. 2201 Dawson Rd Albany, GA 31701' (229) 883-1368 jj I' 11. i- i' " " ,. :1 ]i " Ji FAMILY PRACTICE 1'-'--' ," Bruce G. Hou'ston, D.O.' Michael P.Raines, M.D. Palmyra Park PhysiJians Center' 2002 Palinyra Road, Suite 101 Alban~, GA 3170 I . (229) 432- I 440 , :\ I- ii Terri K.' Johpson, Practic,e ~dminjstrator , I, >- I: 1\ 1\ " Ii , Medical Associates of Albany, D.C: . .~ . - - I _ .II ]I ctober24, 2006 Ii II fl". I; JL 'j~ A I' :: Suzanne Ryan; Administrator, RN :i IntrepidUSA :i' 190 I Palmyra Rd ,I Albany, GA 31701 " I, I 1 , i~ 'I I, I' I / / /AI /A.. ! ( < ({)I.!Ut!urr k.f) ~_ I 4 ' -- - "Charles F. Gebhardt, M.D. , Ii Medical Associates of Albany -I . " ,/ i 'i f Dear Suzanne, Ii ~, I Ii I. ,: I understand that Intrepid has applied to open a Medicare home health agen~y in SSDR8 :: which includes counties where a number of my patients reside, I currently u~e Intrepid ,. - .' .' :1 Home Health services for my patients and have been very pleased with the ej'uality of k . _ _ ., ,i care, It would be beneficial to have additional coverage in these counties to provide. :: continuity of care for my patients and my practice. I f' II I _ . _' _ ~ :~ I fully support your efforts to obtam the, new CON. ' ii I: II 1; ! I, II" I! J .1 . 'i Smcerely,- I I .1 I:' 1; . il 1: 'ii 11 Ii iJ , !, " .Jl -, II 1: ]! ,\ 11 , I' II" r,' t, " . 'I '. > ;[1 1 il. I I ,> . i T .. " )- I ,I !t I INTRRNAL MEDICINR Charles F. Gebh~dt, M.D.. Sterling 1. Barrett, M.D.. Oevell R. Young, M.D. . Palmyra Phk Physicians Center. 2002 Palmyra Road, Suite 101 . '; -Albany, GA 31701' (229) 432-1440 FAMTTYPRAr.TTCE. Thom~ A. Hilsman, M.D. 2201 Dawson Rd Albany, GA 31701. (229) 883-[368 ~i i! ,I li .- F ~~ 1; , \1 FAMILY PR Af'TIC;F: Broce G. Hotstori, D.O. . Michael P. Raines, M.D. Palmyra Park Physibians Center' 2002 Palmyra Road, Suite.1 01 Alba~~, GA 31701 . (229) 432-1440 ! if 'I Terri K. Johnson, Practice Administrator .'/ ORTHOPAEDIC "--ASSOCIATES T. GLENN WILLIAMS, M.D., A.A.D.S., EA.C.S THOMAS M. DARDEN, JR., M.D., A.A.D.S., EA.C.S. PAUL A. MICHAS, M.D., A.A.D.S., F.A.C.S. JAMES S. MASON, D.O., F.A.D.A.D. MARK A. WDLGIN, M.D., A.A.D.S., EA.C.S. Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8, which includes Sumter County. In addition to an office in Albany, I also have an office located in Sumter County. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. Sincerely, ar~ . . T.G. Williams, M.D. P.O. BOX 407 - 2002 PALMYRA ROAD, SUITE 100 - ALBANY, GEORGIA 31702 OFFICE: 229.883-4707 - FAX: 229-435-1038 611-B EAST LAMAR - AMERICUS, GEORGIA 31709 OFFICE: 229-924-2030 - FAX: 229-928-8999 " ~: , I'> Medical Associates of Albany, P.C. :; Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care , ,,1901 Palmyra Rd. :, II Albany, GA 31701 " I . :;. Dear Suzanne , ' ,I 'I It I' Ii :! " " j; , " li " ol! .1 11 " " /, ii , I understand that Intrepid USA has applied to open a Medicare certifi,,~d home 'i health agency in SSDR 8. I: , " " In addition to patients in the Aibany area, many of my patients live in :~he counties 'i located in SSDR 8. I currently use Intrepid USA for the patients in yqur current , service area and am very pleased with the quality of care they receive. I would' use your new agency without hesitation and fe'el it would provide an increased ': continuity of care for my home care patients. II I ' I fully support your efforts to obtain the new CON. " , Sincerel ~- INTERNAl MEDICINE , c:harJes F. Gebhanlt, M.D. . Sterling I. Barren. M.D.' Devell R. Young, M.D. Palmyra Park Physicians Cenler' 2002 Palmyra Road, Suite 101 ,~ AI~any, GA 31701. (229) 432-1440 'I I I twD " '1( " " FAMTI Y PRACTICE Thomas A. Itilsman, M.D. 2201 Dawson Rd Albany, GA 31701' (229) 883-1368" !i l:'hMII Y PRAr:nC:F Bruce G. H~uston, D.O.. Michael P. Raines, M.D. Palmyra Park Physi~ians Cemer' 2002 Palmyra Road. Suite 101 . Alba:ny, GA 31701 . (229) 432-1440 I, . Terri K. Johnson, Practice Administfator . II.. ,i II i~ .' Medical Associates. of Albany, P.C. . ~ 11 " I 1\' j,. i, I' 1; !~ Ij Ii I: II f Suzanne 'Ryan, RN, Administrator i' Intrepid USA Home Health Care ii ]1'1.901 Palmyra Rd. jl 'I Albany, GA31701 i; , 11 I 1 'i' Dear Ms. Ryan" I j. 'I 1\ '..1 understand that Intrepid USA has applied to open a Medicare certified home 'I' health agency in SSDR 8, which includes Sumter, Randolph, Clay, qUitman, . . ',' Stewart, Marion, Schley, Macon,Taylor, Chattahoochee, Talbot and t1arris 'i counties.. il I . II ' : In addition to patients in the Albany area, many of my patients live in these i counties. I currently use Intrepid USA for the,patients in your currentilservice '. ,r area and am veri pleased with the quality of care they receive. I wo:~ld use your ;1 new agency without hesitationandJe.el it would provide an increasedkontinuity ;: of care for my home care patients. . . . ii f . "'l . ill fully support your efforts to obtain the new CON, ?: j- I it Sincerely, 'I , ! ",I. I .:1 , , fi 'i! .~ . ;; . ,I :t !, uce G. Houston, D.O. I, " t ii jl , " Ii i', ii I .I .01' ., ;1 ~ I , ,( :f i I' i; I' II II I~ " i I il . I lNTRRNAI MF1mrlNF1 ,~ ~ . - . Charles F. Gebhardt, MD. . Sterling Ie Barrell, M.D. . Devell R. Young, M.D. Patmyra'P~k Physicians Center' 2002 Palmyra Road, Suite 101 :! Albany, GA 31701. (229) 432-1440 . FAMILY PRACTICE ThomasA. Hilsman, M.D. 2201 Dawson Rd Albany, GA 31701. (229) 883-1368 II , - J;~ PAMll.Y PRACfICE . Bruce G. Houston, D.O. . Micbael P. Raines, M.D. Palmyra Park Physi~ia~s Center. 2002 Palmyra Road, Suite 101 Albariy, GA 31701 . (229) 432-1440 11 I,' . Ii 11' ':F" ~f' :I . Terti K. Johnson, Practice Administrator APPENDIX N Indigent Care ( Intrepid USA Healthcare Services Policy and Procedure Le()licyNarne: . .lll1cji~l!l1trGhllritYGllrl! -<;eorgill : Section: . 2 . .It:Clre [)ElIi"ElI)'.. .If>>()liC:Yt.llJrnber: ! 2.888 GA , EffElctivEl..[)atEl:_!nQC:!()~Elr:g~QO~___. : Revision Date: Policy Statement: To define the processes and required approvals necessary to engage in the provision of services to indigent clients. The agency will provide care to all clients regardless of the client's ability to pay, as allowed by agency resources. Indigent care is defined as all unpaid charges for services to clients whose family income level was equal to or less than one-hundred-fifty (150) percent of Federal Poverty Guidelines, excluding those unpaid charges classified as contractual allowances for Medicare or other free care such as courtesy allowances, policy discounts, and administrative adjustments. Guidelines I Procedures: 1. Clients who are unable to pay for services are accepted for care under certain conditions. 2. If there is no third-party source for reimbursement of services, the client (or his/her guarantor) is responsible for payment. 3. Cases arise whereby the client or guarantor is financially unable to pay for service due to income. The ability to provide funding to those clients who do not have the means to pay is limited to the amount designated for that purpose by the agency. 4. The Referral/Intake staff obtain and verify insurance and financial information from the client or referring party. Staff verifies insurance coverage. 5. If a client is determined to have no third party payor source and the client is unable to pay for home health services, the Intake nurse will consult with the Administrator and/or the Director of Professional Services, and the Social Worker to determine and document the financial condition of the client. 6. Based on the documented financial information and other pertinent documentation of the client's conditions and needs, after consultation with the physician, and with the approval of the Administrator, the home care plan will be established 7. Medical Social Workers may also evaluate and document the financial condition of the client when Medicare B Outpatient and/or private insurance payor sources do not cover the total cost of services, and outstanding balances are anticipated, and when possible, will assist the client in identifying alternate funding sources. 8. It is anticipated that some clients will exhaust their benefits from their payment source prior to the time when home health care is no longer needed. The Medical Social Worker will help these clients to secure an alternative payment source, if available. If no alternative is available, these clients will be reclassified as indigenUcharity, as appropriate. It will be the policy of the Company to continue to provide services to these clients as long as care is warranted. Intrepid USA Healthcare Services Indigent I Charity Care - Georgia Page 1 of2 Policy 2.888GA Intrepid USA Healthcare Services Policy and Procedure 9. In addition to the agency criteria for admission, which address appropriateness of home health care and staff safety, the following guidelines are applied when providing uncompensated care to clients: a. The client and/or family accept the program of care in the home and agree to learn to independently manage health care needs. b. The client/family provides all supplies and pharmaceuticals necessary to manage health care needs. c. The agency will not accept clients who require two (2) or more visits per day without appropriate compensation from the discharging institution. The Director of Client Care and Administrator negotiates this on a case-by-case basis. d. Referrals to the agency for uncompensated care must include a Social Work referral. e. Cases accepted outside of the above guidelines must be approved in advance by the Director of Client Care, or the agency Administrator. 10. If the agency is unable to admit the client or to continue to deliver service, every effort will be made to refer the client to an appropriate institution, state, local, or county agency for needed care. Intrepid USA Healthcare Services Indigent I Charity Care - Georgia Page 2 of 2 Policy 2.888GA APPENDIX N Community Linkage ( COMMUNITY LINKAGE Hospital DFACS Outpatient Therapy Home Health Agency Ie) Pharmacy Ambulatory Surgery Center Infusion Rehab Facility Physician Office . Assisted Living Facility Regional Development Center - . :... :"--". APPENDIX N CHAP Accreditation Letter i!11E~!pldf we find a way. November 2, 2006 CHAP Community Health Accreditation Program, Inc. 39 Broadway, Suite 710 New York, NY 10006 RE: F.e. of Georgia, Inc. d/b/a Intrepid USA Healthcare Services To Whom It May Concern: The purpose of my letter is to notify your office of our intent to apply for CHAP accreditation for onc of our Georgia providers. Intrepid is applying for a Certificate of Need in Georgia to establish a new home health agency in Southwest Georgia (SSDR8) and if awarded we will prepare and mail the CHAP application. As you are aware, Intrepid USA Healthcare Services is in the process of accrediting its locations in the State of Virginia. 1 have the CHAP Application for Accreditation on line, is it ok for me to use it to prepare our Georgia application? In my cover letter accompanying the application I will give you the projected net annual revenues for your calculation of the application fee. If you need to contact me please call 952-285-7359 or you may cmail to ccallis(ai,intreoidusa.com . Sincerely; ~~ Cecelia Callis VP of Compliance Corporate Service Center 6600 France Avenue, Suite 510 Edina, Minnesota 55435 TeI952.285.7300 Fax 952.920.3316 www.intrepidusa.com -8 _.~ APPENDIX N QAJPI Intrepid USA Healthcare Services Policy and Procedure L PolicYlIlarne: i Performance Improvement Program Section: . 4 . QualityManagement : f>>olicy Num 4.001 Effective Date: 1I\11Circh1,2QQO : Revision Date: : J.\prH2006,JLI'y?QQ~ Policy Statement: Agency management is responsible for the development and implementation of a Performance Improvement (PI) Program. Performance improvement, as an ultimate goal, is the end result of developed standards, quality assurance activities, and enhanced employee performance. Performance improvement principles require actions that are both proactive and retroactive. The PI Program is a systematic, integrated and principled approach to process design, implementation, measurement, and evaluation. Agencies will re-evaluate their strategies if quality is not readily evident in services or in the functions and processes that support the service provision. Quality improvements are based on data or evidence but always focused on the customer. The achievement of quality is obtaining or exceeding the expected results or outcomes. It is the result of intelligent effort and planned design. Definitions: Active Records: Clinical records of active clients during the time period under review. Inactive Records: Clinical records of clients discharged during the time period under review. Review Periods: The Performance Improvement Program is reviewed quarterly. Quarterly Report: Information is gathered from Grievances/Complaints, Client/Customer Satisfaction Surveys, Event Reports, Client and Employee Infection Logs, Clinical Outcome Reports, Tier Audit/regulatory surveys, and any agency plans of action / correction. The agency may include information from regional/national data related to like-agencies, operational or business trends, internal process success rates, resource management trends, industry practice standards for disease management, and clinical outcome benchmarks. Tier I Audit: Specified audit structure conducted monthly by agency management to examine clinical record components, personnel file components, and supporting agency infrastructure. Tier II Audit: Audit performed by Company auditor to confirm an agency's Tier I Audit results. Tier III Audit: Comprehensive audit conducted by Company auditor which includes all Medicare conditions of participation requirements and/or state regulation. OBQIIOBQM Reports: Agency-specific clinical outcome reports derived from OASIS assessment data available for national benchmarking capability. Performance Improvement Committee: Agency level structure established for Performance Improvement projects and implementabon. Intrepid USA Healthcare Services Performance Improvement Program Page 1 017 4.001 Intrepid USA Healthcare Services Policy and Procedure Guidelines I Procedures: 1. Company agencies will have an effective performance improvement program designed to systematically measure, assess, and improve the quaiity of care and services provided by the agency. 2. Performance improvement activities will reflect the agency's mission, goals and vision. 3. The Performance Improvement Committee, lead by the agency Administrator, should consist of representation of all professional disciplines providing care, agency administrative staff, and other agency personnel as designated or required by regulation. 4. The Performance Improvement Committee will convene at least quarterly to analyze agency data related to the dimensions of care, performance improvement projects, clinical outcomes, employee or client safety, and customer satisfaction. Committee members will draft agency performance summary reports and project plans. 5. Agencies that provide supplemental staffing will, at a minimum, collect data related to customer satisfaction to identify opportunities for improvement. 6. Agencies will use the Company's assessment tools to establish consistency in data collection to: a. identify, design, and assess new processes b. assess and measure dimensions of performance c. identify areas for improvement and evaluate the results of changes made to improve outcomes 7. The process for collection of data will include time frames for collection. Statistical techniques for analysis will be used to ensure that outcomes for client care, agency functions, process and quality are appropriate and that client and customer satisfaction is continuously achieved. 8. Data is collected on a routine basis for the purposes of performance improvement and includes (at a minimum) the following elements: a. Client Satisfaction b. Clinical Record Review c. Tier Audits and Regulatory Surveys with current and applicable previous Action Plans d. Employee Personnel File Review e. Client and Employee Infection Control and Surveillance f. Client Event Reports g. Grievances / Complaints h. Customer (Vendor Satisfaction) for supplemental staffing agencies i. OBQI/ OBQM Outcome Reports j. Employee First Reports of Injury 9. Improvement strategy may be implemented system-wide or may encompass only a limited area of concern or staff performance. Agency management will utilize Performance Improvement Program findings to review their service programs, practices, procedures and outcome targets 10. Reports of program activities will be provided to agency staff on an ongoing basis. 11. Each improvement activity will include the following: a. Recommended actions and an accountable person responsible for each b. Time frame for implementation c. Expected outcome d. Monitoring activities e. Need for ongoing monitoring after each action/monitoring cycle f. Documentation of improvement activity Intrepid USA Healthcare Services Performance Improvement Program Page 2 of 7 4.001 Intrepid USA Healthcare Services Policy and Procedure 12. Previous successful performance improvement targets will continue to be monitored by the agency periodically as needed to assure that the level of improvement is sustained. 13. Data summary reports, project plans and Performance Improvement Committee meeting minutes will be submitted quarterly to the Compliance/Regulatory Department. 14. A written report of the performance improvement findings and recommendations will be submitted to the Professional Advisory Committee and Governing Body at least annually, or as required by state regulation. Performance Improvement Elements: Client Satisfaction 1. The purpose of evaluating client satisfaction is to: a. determine the client's satisfaction with care and services b. determine causal factors for dissatisfaction c. identify opportunities for improvement 2. Satisfaction surveys are sent to clients at the time of discharge and annually during the third quarter if the client has been on service for more than a year to provide the agency with comprehensive information to improve care, processes, and services offered. 3. Survey results are recorded and reviewed quarterly. Clinical Record Review The Tier I Audit structure is used for clinical record review by appropriate health professionals, representing at least the scope of the program. Samples of both active and closed clinical records are used. Quarterly, at least 10% of the current census will be reviewed. 1. Clinical record review is a method of systematic evaluation of the documentation in the clinical record conducted in accordance with state and federal regulations. 2. The purpose of the review is to insure that: a. Service is provided according to the treatment plan b. Company policies are followed in providing care c. Needs of clients are being met. d. Coordination of care is provided within the agency, with physicians and across the health care continuum. e. Components of services that are not available within the agency and/or community are identified f. Services are provided efficiently and effectively to promote, achieve and maintain the client's optimum state of health and function 3. Agencies may be required to supplement the number of records for review when Tier I Audit criteria do not yield sufficient numbers to meet applicable state and federal clinical record review requirements. 4. The size of the sample will vary depending on the number of clients serviced and applicable state requirements for sample size. The sample will include a representative aggregate of both inactive and active client records. The Administrator is responsible for ensuring that an adequate number of records are audited for the time period under review. 5. Records selected for review shall include records that reflect: a. all services being provided by the agency directly or under contract. b. records from all branch locations. c. records that contain each type of OASIS assessment: Start/Resumption of Care, Follow-up/ Recertification, Transfer, and Discharge for Medicare certified agencies. d. Clients identified on the Adverse Event Outcome Report. Intrepid USA Healthcare Services Performance Improvement Program Page 3 of 7 4.001 Intrepid USA Healthcare Services Policy and Procedure Tier Audits and Regulatory Surveys 1. The Administrator is responsible to ensure the completion of monthly Tier 1 Audits, which include the following components: a. Environmental- Review of daily operations for compliance with broad regulatory issues. b. Personnel - Review of a portion of employee files for required elements. c. Medical Record Review - Review and analysis of required client medical record elements 2. Areas within the audit with "No" answers or less than 100% compliance are identified and a corrective Project IAction Plan is initiated and implemented by the Administrator. 3. The Administrator informs appropriate agency staff of results and assigns corrective actions according to Tier Audit Project Plan as appropriate. Administrator or designee monitors Tier Audit Project Plan to ensure that corrective actions are followed by agency employees as directed. 4. Results of the Tier Audits are reported to the Performance Improvement Committee. A copy of the Tier Audit Project Plan is attached to the Performance Improvement Committee meeting minutes, if applicable. 5. Tier 2, Tier 3 and Focused Audits are conducted by non-agency employees. The corresponding Project Plan development, implementation and evaluation are congruent with the Tier Audit structure. 6. Additional audits or surveys are conducted by various state and federal regulatory agencies. The surveys are conducted to determine compliance with required regulation. Deficiencies, when identified, must be corrected by drafting a plan of correction, approved by the RVP, CompliancelRegulatory Department, and implementing that plan. 7. Agency management will examine current and previous regulatory survey findings for trends associated with their existing Performance Improvement Program. Tier I Audit Requirements Average Daily Census Between Combined Parent Medical Records Employee Personnel Files and all Branches Less than 50 4 10% are reviewed monthly. The 51 -100 4 agency selects the files of the most 101 -150 5 recently hired employees and 151-200 7 supplements the audit with remaining 201 - 300 10 employees to assure all employee files 301 - 400 14 are reviewed annually. All new 401 - 500 17 employee files are reviewed, even if 501 - 600 20 the new employee number is greater Greater than 600 4% of Averaae Dailv Census than required by audit. Employee Personnel File Review 1. Employee Personnel File review is a method of systematic evaluation of the employee file and the application of resource management. 2. The purpose of the Employee Personnel File review is to insure that: a. required actions were taken pre-hire (checking references, application completed, OIG-GSA etc.) b. required actions were taken upon hire (criminal background checks, license verification, etc.) c. the employee has documented competencies and the required amount of on-going training d. performance evaluations are provided on a timely basis e. a separate medical file is maintained for all medical issues (hepatitis B vaccine, physicals, etc.) f CIA Training is documented Intrepid USA Healthcare Services Performance Improvement Program Page 4 of 7 4.001 Intrepid USA Healthcare Services Policy and Procedure Client and Employee Infection Control Surveillance 1. The purpose of evaluating infection control data is to: a. improve client health outcomes through identification and risk reduction of procedure-related and device-related infections b. identify trends and patterns with employee and client infections c. determine opportunities for improvement 2. Data is routinely collected and reported quarterly for performance improvement purposes. Client Events 1. Client events include but are not limited to: a. care-related issues b. client-related accidents/injuries c. medication errors d. employee-related issues e. ProcedurelTreatmenVEquipment-related issues f. HIPAA violations. 2. The purpose of tracking reportable events is to: a. identify patterns with practice issues b. identify trends with client injuries c. identify cases with potential liability for the agency or the Company d. identify events that can be prevented. 3. Data on events that predispose the organization to real or potential liability: a. is collected, documented, and analyzed as soon as possible after the event, and b. is incorporated into Performance Improvement Program, as applicable, to indicate appropriate organizational change related to the event. 4. Data is routinely collected and reported quarterly for performance improvement purposes. Employee Events 1. All employee related accidents, injuries, and conditions are documented and reported to the Company's workers' compensation insurance carrier who prepares the state specific First Report of Injury. 2. The purpose of tracking employee events is to: a. identify patterns with practice issues b. identify trends with employee injuries/accidents c. identify claims with potential liability for the agency and/or the Company d. identify events that could be prevented 3. Data on all reported/known employee accidents, injuries, and conditions is collected, documented, analyzed and reported quarterly for performance improvement purposes. Grievances I Complaints 1. The purpose of tracking grievances and complaints is to: a. provide an avenue for clients or employees to offer suggestions either formally or informally b. identify opportunities for improvements in practice or process c. determine needs for training or education 2. Data is routinely collected and reported quarterly for performance improvement purposes. Intrepid USA Healtheare Services Performance Improvement Program Page 5 of 7 4.001 Intrepid USA Healthcare Services Policy and Procedure Customer Satisfaction 1. The purpose of customer satisfaction surveys is to allow agencies to: a. identify opportunities for improvement related to external customers b. determine processes that may require revision to assure customer satisfaction c. evaluate the outcomes of staffing placement d. identify systems that need improvement to increase customer satisfaction 2. Data is collected at least twice a year by agencies providing supplemental services and reported for performance improvement purposes. Outcome Based Quality Improvement/Outcome Based Quality Maintenance (OBQI/OBQM) Continuous quality improvement is both a process and a mind set. It requires the organization to regularly identify, implement, and evaluate their efforts to improve. Outcome-Based Quality Improvement (OBOI) and Outcome-Based Ouality Monitoring (OBOM) represent a continuous quality improvement approach. 1. Medicare certified agencies will collect the OASIS data using methods, practices, and strategies that ensure the data collection and interpretation is both reliable and valid. OASIS data is transmitted to the state following established regulatory guidelines. 2. Clinical outcome reports should be reviewed as often as appropriate to analyze progress in improving clinical outcomes and analyzing agency population characteristics. 3. Agency management will assist staff in the interpretation of data reports for clinical outcomes. 4. Clinical outcomes targeted for improvement across the agency's clinical popuiation will be established using the following criteria: a. problem prone to the agency, its customers, or clients, b. likely to generate a significant impact, c. statistically significant as indicated from outcome reports analysis, d. relevant to agency goals, and e. clinically significant for the population served. Additional Performance Improvement Elements 1. Agency management may select additional elements to monitor their performance improvement. Additional data collection elements include: a. Regional or national data related to like-agencies b. Operation I Business Trends c. Internal Process Success Rates d. Resource Management Trends e. Industry Practice Standards for Disease Management f. Clinical Outcome Benchmarks 2. Data is routinely collected and reported quarterly for performance improvement purposes. Integration of Performance Improvement Indicators 1. Elements of data from Client Satisfaction surveys, Clinical Record Review results, Tier Audits and Regulatory Surveys, Employee Personnel File Reviews, ClienUEmployee Infection Control Surveillance logs, Client Event Reports, Grievances I Complaints, Customer Satisfaction surveys, OBOI I OBOM and Outcome Reports are the basis of the agency's Performance Improvement Program. Intrepid USA Healthcare Services Perfonnance Improvement Program Page 6 of 7 4.001 Intrepid USA Healthcare Services Policy and Procedure State Specific Reauirements: Arizona: Clinical record review will be conducted by professionals representative of services provided during the previous quarter review. The quantity of reviews will be a ten percent (10%) sample or thirty (30) records whichever is lesser. Arkansas: In conducting clinical record reviews, a minimum of ten percent (10%) of both active and closed records shall be reviewed. A minimum of ten (10) records per quarter is required if the case load is less than ninety-nine (99). Indiana: Agencies providing personal services must conduct a client satisfaction review with the client every seventy-six (76) to one hundred four (104) days to discuss the services and determine if the plan of services requires a change. The client satisfaction review must be in writing, signed and dated by the person conducting the review. Mississippi: The clinical records of at least ten percent (10%) of the total client census is to be reviewed every quarter; however, at no time shall the review consist of less than ten (10) or more than fifty (50) records. Rhode Island: Each licensed health care facility shall establish and maintain records and data in such a manner as to make uniform a system of periodic reporting to the Health Care Quality Performance Measurement and Reporting Program. The manner in which the requirements may be met shall be prescribed in directives promulgated by the Director. The customer satisfaction survey instrument in a standardized format to facilitate public reporting shall be approved by the Director after consultation with the Health Care Quality Steering Committee. South Carolina: The quality improvement program will include risk management and the causes of deviation from expected outcomes. Quality care indicators will include the appropriateness of the combination of services/mix of professionals reflected on the plan of care and the effectiveness of communication between agency staff. Texas: Performance Improvement Committee membership will include representation from unskilled disciplines providing services. The Performance Improvement Program will include review of the issues of unprofessional conduct by licensed staff and misconduct by unlicensed staff. Agencies must immediately correct identified problems that directly or potentially threaten client care and safety. Agencies must include corrective action in to insure that improvements are sustained over time. Virginia: Clinical record review will represent a ten percent (10%) sample for a maximum of fifty (50) medical records of active clients and a five percent (5%) sample or maximum of twenty-five (25) discharged cases. The sample will reflect services provided, including contracted. Intrepid USA Healthcare Services Performance Improvement Program Page 7 of 7 4.001 I I ,I I ! Ii i: II II APPENDIX N I Ii II Ii 11 i I I I I I Ii Ii ! II Ii Ii I' II II I II II 'I Ii Ii MDC & Product Line Reports Health Service Demand Estimates Major Diagnostic Categories Report Geography: Georgia Site-IntrepidUSA Healthcare CURRENT YEAR MDC DESCRIPTION DISCHARGES 0 OTHER DRG'S NOT ASSOCIATED WITH ANY MDC 155 1 DISEASES & DISORDERS OF THE NERVOUS SYSTEM 877 2 DISEASES & DISORDERS OF THE EYE 45 3 DISEASES & DISORDERS OF THE EAR NOSE MOUTH & THROAT 220 4 DISEASES & DISORDERS OF THE RESPIRATORY SYSTEM 1,905 5 DISEASES & DISORDERS OF THE CIRCULATORY SYSTEM 2,668 6 DISEASES & DISORDERS OF THE DIGESTIVE SYSTEM 1,503 7 DISEASES & DISORDERS-HEPATOBILlARY SYS & PANCREAS 495 8 DISEASES/DISORDERS-MUSCULOSKELETAL & CONN. TISSUE 1,379 9 DISEASES/DISORDERS-SKIN SUBCUTANEOUS TISSUE BREAST 514 10 ENDOCRINE NUTRITIONAL METABOLIC DIS/DISORDERS 832 11 DISEASES & DISORDERS OF THE KIDNEY & URINARY TRACT 713 12 DISEASES & DISORDERS OF THE MALE REPRODUCTIVE SYS 100 13 DISEASES & DISORDERS OF FEMALE REPRODUCTIVE SYSTEM 489 14 PREGNANCY CHILDBIRTH AND THE PUERPERIUM 2,512 15 NEWBORNS/OTHER NEONATES/CONDITIONS IN PERINATAL PER. 2,174 16 DISEASES/DISORDERS-BLOOD ORGANSIIMMUNOLOGICAL 257 17 MYELOPROLIFERATIVE DISEASES/DISORDERS & NEOPLASMS 170 18 INFECTIOUS & PARASITIC DISEASES 331 19 MENTAL DISEASES & DISORDERS 897 20 ALCOHOL/DRUG USE & INDUCED ORGANIC MENTAL DISORDERS 213 21 INJURY POISONING & TOXIC EFFECTS OF DRUGS 262 22 BURNS 83 23 FACTORS INFLUENCING HEALTH STATUS/OTHER HEALTH SERV. 307 24 MULTIPLE SIGNIFICANT TRAUMA 46 25 HUMAN IMMUNODEFICIENCY VIRUS INFECTIONS 65 Copyright: Medical Management Advisors, Inc. 1988-2006, ESRI 2004-2006 Thursday October 5, 2006 Health Service Demand Forecast Home Health Product Line Report Geography: Georgia Site - IntrepidUSA Healthcare CASES FROM HOSPITAL DISCHARGES ESTIMATED PROJECTED CONGESTIVE HEART FAILURE 110 105 INFUSION THERAPY 522 513 OB/GYN 205 202 ONCOLOGY 398 397 PSYCHIATRIC 89 92 PULMONARY 156 150 WOUND CARE 452 453 TOTAL ALL PRODUCT LINES FOR SITE 1,932 1,912 Copyright: Medical Management Advisors, Inc. 1988-2006, ESRI 2004-2006 Thursday October 5, 2006 APPENDIX N Scope of Services Intrepid USA Healthcare Services Policy and Procedure Name: Scope of Services Section: 2 Care Number: 2.007 Effective Date: October 1 1999 Revision Date: March 2006 Policy Statement: The agency will provide skilled and non-skilled/ancillary services to its clients in accordance with the Plan of Care (POC) ordered and approved by the client's physician when required by regulation. Services are provided either directly or through contractual arrangements. All services listed may not be available at all locations. Basic medical services (skilled and non-skilled) may include, but are not limited to the following: a. Skilled Nursing b. Physical Therapy c. Occupational Therapy d. Speech-Language Pathology e. Medical Social Services f. Nutritional Services g. Home Health Aide h. Homemaker i. Sitler/Companion j. Personal Care Atlendant Verification of education, training and experience of all personnel providing client care or service will be performed by the agency. Assignment of responsibilities will be determined by education and experience, and the specific needs of the client, and will be made without regard to race, sex, age, color, religion, creed, natural origin, veteran status, disability or handicap. Guidelines I Procedures: Staff (agency and contracted) providing direct client care will participate in care coordination as required by regulation. Skilled Nursina Services: Skilled nursing service is rendered by a nurse (Registered Nurse [RN] or Licensed Practical Nurse/Licensed Vocational Nurse [LPN/L VN]) under the supervision of an RN and in accordance with the plan of care. All nurses will be currently licensed in the state in which practicing. Nursing personnel must comply with all Practice Acts and other applicable regulatory requirements that govern the provision of nursing services in the state where the care is provided. Types of skilled nursing services include, but are not limited to: medical-surgical, psychiatric, pediatric, maternal- child health, wound management, cardiovascular, diabetic, restorative, infusion therapy, terminal care, skilled respite, palliative, or other skilled nursing ordered by the physician. All initial evaluations for nursing are completed by the RN. The RN determines if the plan of care can effectively be provided to the client by the LPN/L VN prior to assigning the client to the LPN/L VN. In addition, all clients Intrepid USA Healthcare Services Scope of Services Page 1 of 9 2.007 Intrepid USA Healthcare Services Policy and Procedure being seen by the LPN/L VN are seen by the RN prior to the client's recertification to reevaluate the plan of care and client status to ensure that the care can continue to be safely and effectively provided by an LPN/L VN. The RN makes supervisory visits to clients receiving skilled services by the LPN/L VN as needed based upon the severity of the client's medical condition and the LPN/L VN's training experience, unless otherwise specified by state regulation. The REGISTERED NURSE: 1. Evaluates the client's initial and on going nursing needs. 2. Initiates, develops, implements, and makes revisions as necessary to the nursing component of the client POC and coordinates the services of all agency team members. 3. Provides nursing services, treatments, and diagnostic preventative procedures requiring substantial specialized skills. 4. Leads the Care Coordination Conference. 5. Initiates preventative and rehabilitative nursing procedures as appropriate for the client's care and safety. 6. Observes signs and symptoms, observes the client's response to treatments (including medications), and changes in the client's physical and emotional condition. Reports observations and changes to the physician. 7. Teaches, supervises and counsels the client and family members regarding the nursing care needs and other related client problems. 8. Makes home health aide, homemaker, companion, sitter and/or LPN/L VN supervisory visits, in accordance with Company policy, to provide supervision, assess relationships and determine whether goals are being met. 9. Prepares clinical notes, progress notes, summary reports, interdisciplinary care conference notes, and discharge/transfer summaries. 10. Ensures the client's nursing care progress is recorded in the clinical record. 11. Assists in the development of written policies and procedures for nursing services of the home care agency as requested. 12. Participates in in-service programs. The LPN/LVN: 1. Observes, records and reports to the supervisor on the general physical and mental conditions of the client. 2. Administers prescribed medications and treatments within the LPN/L VN scope of practice and in accordance with agency policies and the POCo 3. Assists the physician and/or RN in performing specialized procedures. 4. Prepares equipment and materials for treatments observing sterile/aseptic technique as required. 5. Assists the client with activities of daily living and encourages appropriate self-care techniques. 6. Prepares clinical notes and progress notes. 7. Completes other duties as directed by the RN. Phvsical Therapv Services: A Registered Physical Therapist or a Physical Therapy Assistant under the supervision of a Physical Therapist who is currently licensed in the state in which is practicing renders physical therapy services. Care is provided in accordance with an evaluation and plan of care mutually established and approved by the therapist and the client's physician. Intrepid USA Healthcare Services Scope of Services Page 2 of 9 2.007 Intrepid USA Healthcare Services Policy and Procedure Types of physical therapy services include, but are not limited to: therapeutic exercises, gait training, hydrotherapy, ultrasound, electrotherapy, prosthesis and assistive device training, fabrication of temporary orthotic device, muscle reeducation, chest physiotherapy, wound debridement or other physical therapy services ordered by the physician. The PHYSICAL THERAPIST: 1. May complete the initial evaluation and admission for clients receiving physical therapy only, unless otherwise specified per state specific regulations. 2. Assists the physician in the functional evaluation of the client and development of the individual POCo 3. Initiates, develops, revises as necessary, and implements a physical therapy POCo 4. Renders treatments to relieve pain, develop and restore function, and maintain maximum performance. Directs and aids the client in active and passive exercises, muscle re-education and engaging in functional training activities in daily living. 5. Evaluates the client's response to treatments and changes in the client's condition and reports observations and changes to the physician. 6. Instructs the client and family on the client's total physical therapy program, including the care and use of appliances and other orthopedic devices. 7. Prepares clinical notes, progress notes, summary reports, interdisciplinary care conference notes, and transfer/discharge summaries. 8. Acts as a consultant to other agency personnel. 9. Instructs home health aide on range of motion exercises. 10. Participates in in-service programs. 11. Assists in the development of written policies and procedures for physical therapy services of the home care agency as requested. 12. Supervises physical therapy assistant(s) as specified by state specific regulations or no iess than monthly and is accessible by telecommunications to the physical therapy assistant(s) at all times while the physical therapy assistant is treating clients. 13. Coordinates the termination of the POC with the physical therapy assistant. The PHYSiCAL THERAPY ASSISTANT: 1. Performs physical therapy procedures and related tasks selected and delegated by the supervising physical therapist. 2. Notifies the supervising physical therapist of changes in the client's status. 3. Discontinues immediately any treatment procedures, which in their judgment, appear to be harmful to the client and notifies the supervising physical therapist. 4. Prepares clinical notes and progress notes. 5. Participates in educating the client and family. 6. Participates in in-service programs. Speech-Language Pathologv Services: Speech-language pathology service is rendered by a speech-language pathologist currently licensed in the state which practicing and in accordance with an evaluation and POC mutually established and approved by the therapist and the client's physician. Intrepid USA Healthcare Services Scope of Services Page 3 of9 2.007 Intrepid USA Healthcare Services Policy and Procedure Types of speech-language pathology services include, but are not limited to: expressive and perceptive language training, articulation training techniques to augment communication, non-oral communication training, swallowing/feeding techniques associated with dysphagia and other speech-language pathology services ordered by the client's physician. The SPEECH-LANGUAGE PATHOLOGIST: 1. Evaluates the client's speech, language and swallowing abilities. 2. Initiates, develops and implements the Speech-Language component of the POCo 3. Plans and administers diagnostic and rehabilitative techniques/services for speech and language and/or swallowing disorders, utilizing assistive devices as appropriate. 4. Evaiuates the client's response to therapy and reports the client response to the physician. 5. Prepares clinical notes, progress notes, summary reports, and interdisciplinary care conference notes. Prepares transfer/discharge summary upon client discharge. 6. Instructs and counsels the client, caregivers, other health team personnel in methods of assisting client in improving, correcting and accepting his disabilities. 7. Assists in the development of written policies and procedures for speech therapy services of the home care agency as requested. 8. Participates in in-service programs. Occupational Therapy Services: An Occupational Therapist or an Occupational Therapy Assistant, under the supervision of an Occupational Therapist, who is currently licensed in the state in which is practicing, provides Occupational Therapy services. Care is provided in accordance with an evaluation and plan of care mutually established and approved by the therapist and the client's physician. Types of occupational therapy services inciude, but are not limited to: muscle reeducation, perceptual motor training, dexterity motor training, neuro-development training, functional and independent activities of daily living training, sensory enhancement, fabrication of splints and orthotics and other generalized occupational therapy services ordered by the client's physician. The OCCUPATIONAL THERAPIST: 1. Assists the physician in the evaluation of clients by applying diagnostic and prognostic tests, by reporting the findings in terms of problems or abilities of the client, and by identifying client's therapy needs and development of the individual POCo 2. Initiates, develops, revises as necessary, and implements an occupational therapy component of the plan of care. 3. Treats clients for the purpose of attaining maximum functional performance through the use of such procedures as: a. Task orientated therapeutic activities b. Activities of daily living c. Perceptual motor training and sensory integrative treatment d. Orthotics and splinting e. Use of adaptive equipment f. Prosthetic training g. Homemaking training 4. Observes, records and reports to the physician and agency personnel the client's reaction to treatment and any changes in the client's condition. Intrepid USA Healthcare Services Scope of Services Page 4 of 9 2.007 Intrepid USA Healthcare Services Policy and Procedure 5. Counsels client and caregiver with regard to the levels of functional performance and the availability of community resources. 6. Instructs clients, caregivers and other health team personnel. 7. Prepares clinical notes, progress notes, summary reports, interdisciplinary care conference notes, and transfer/discharge summaries. 8. Supervises occupational therapy assistants as specified by state specific regulations or no less than monthly and is accessible by telecommunications to the occupational therapy assistant(s) at all times while the occupational therapy assistant is treating the client. 9. Reviews and countersigns written documentation performed by the occupational therapy assistant where required by state regulation. 10. Conducts all initial assessments and establishes the goals and plans of care before care is provided by an occupational therapy assistant. 11. Initiates any changes in the POC for client treated by the occupational therapy assistants. 12. Coordinates the termination of the POC with the occupational therapy assistant. 13. Assists in the development of written policies and procedures for occupational therapy services of the home care agency as requested. 14. Participates in in-service programs. The OCCUPATIONAL THERAPY ASSISTANT: Performs occupational therapy procedures and related tasks selected and delegated by the supervising occupational therapist. Treats clients for the purpose of attaining maximum functional performance through the use of procedures such as: a. Task oriented therapeutic activities b. Activities of daily living c. Perceptual motor training and sensory integrative treatment d. Orthotics and splinting e. Use of adaptive equipment f. Prosthetic training g. Homemaking training h. Client and family member education Observes, records and reports to the supervising occupational therapist changes in the client's condition and response to treatment. Prepares clinical notes and progress notes. Participates in in-service programs. Medical Social Services: Medical Social Service is rendered by a qualified social worker or a qualified social work assistant under the supervision of a qualified social worker who currently meets all educational and licensing criteria per the state requirements in which practicing. The medical social worker works in conjunction with agency personnel to provide rehabilitative and supportive care. Medical social services are provided in accordance with the physician's written order. Types of medical social services include, but are not limited to: counseling of clients and families, community resource planning, long range living plans, assessing social and emotional factors impacting the client's rate of recovery and other medical social services ordered by the client's physician. Intrepid USA Healthcare Services Scope of Services Page 5 of 9 2.007 Intrepid USA Healthcare Services Policy and Procedure The QUALIFIED SOCIAL WORKER/QUALIFIED SOCIAL WORK ASSISTANT: 1. Assists the physician and other members of the agency care team in understanding the significant social and emotional factors related to client's health problems and acts as a consultant to other agency personnel. 2. Assesses the social and emotional factors in order to estimate the client's capacity and potential to cope with problems of daily living. 3. Initiates, develops and implements a social work component of the POCo 4. Uses appropriate community resources. 5. Participates in discharge planning. 6. Helps the client and caregiver understand, accept and follow medical recommendations. Provides services planned to restore the client to optimum social, emotional and physical health within his capacity. 7. Assists clients and caregivers with personal and environmental difficulties that predispose them to illness or impacts the rate of recovery. 8. Prepares clinical notes, progress notes and discharge summaries. 9. When medical social services are rendered by a qualified social work assistant it is under the supervision of a qualified social worker. This supervision will occur on an as needed basis but no less often than every 60 days, unless otherwise specified by state regulation or State Social Work Practice Act. 10. Participates in in-service programs. Nutritional CounselinQ Services: Nutritional counseling services will be provided in accordance with the POC and by or under the supervision of a physician and/or Registered Dietician. Types of nutritional counseling services include, but are not limited to: evaluating the dietary needs of the client, teaching the client and family dietary modifications, assessing the client's response to dietary treatment, food and drug interactions, and instructing other health care team members regarding dietary care of the client. The NUTRITIONAL COUNSELOR: 1. Evaluates the client's nutritional status and develops the plan of care with the client and physician. 2. Evaluates the client's response and reports observations and changes to the supervising RN and/or physician. 3. Prepares clinical notes and progress reports. Home Health Aide Services: A home health aide is assigned when the client needs personal care. The services are provided under a physician's order and supervised by a Registered Nurse (RN), as per state specific regulations. When appropriate, supervision may be given by a physical, speech or occupational therapist. Written client care instructions for the home health aide must be prepared by the RN or appropriate therapist who is responsible for the supervision of the home health aide. The HOME HEALTH AIDE: Performs only those personal care activities contained on the POC and home health aide plan of care assignment sheet. Performs activities as taught and delegated by the health professional which may include, but are not limited to: a. Bathing/shampoo and other aspects of personal hygiene b. Dressing Intrepid USA Healthcare Services Scope of Services Page 6 of 9 2.007 Intrepid USA Healthcare Services Policy and Procedure c. Assisting with ambulation and transfers d. Assisting with range of motion exercises e. Measuring and preparing special diets f. Feeding g. Intake and output h. Vital signs i. Reinforcement of a dressing Prepares clinical notes, which includes tasks that were performed and reasons assigned tasks were not performed, if applicable. Reports to the registered nurse any client care problems and/or observed appearance and behavioral changes in the client. Assists with medications, if qualified, in accordance with state specific regulations. Participates in in-service programs. The PERSONAL CARE A TTENDENT 1. Performs only those personal care activities contained on the plan of care and personal care aide plan of care/assignment sheet. 2. Performs activities as taught and delegated by the health professional which may include, but are not limited to: a. Bathing/shampoo and other aspects of personal hygiene b. Dressing c. Assisting with ambulation and transfers d. Assisting with range of motion exercises e. Measuring and preparing special diets f. Feeding g. Intake and output h. Vital signs i. Reinforcement of a dressing 3. Prepares notes, which includes tasks that were performed and reasons assigned tasks were not performed, if applicable. 4. Reports to the registered nurse any client care problems and/or observed appearance and behavioral changes in the client. 5. Assists with medications, if qualified, in accordance with state specific regulations. 6. Participates in in-service programs. Homemaker Services: Homemaker services are provided by a trained homemaker who has received training in topics related to human development and interpersonal relationships, how to stabilize clients during ambulation, nutrition, food selection, storage and preparation, equipment and supplies, planning and organizing household tasks, and principles of cleanliness and safety. Homemaker services are provided to clients who are unable to perform independent functional activities of daily living, or when the individual who is regularly responsible for these functions is temporarily absent or functionally unable to manage the client's home. Homemakers do not perform activities related to personal care/hygiene. Intrepid USA Healthcare Services Scope of Services Page 7 of9 2.007 Intrepid USA Healthcare Services Policy and Procedure The HOMEMAKER: 1. Performs only those activities contained on the plan of care/assignment sheet. 2. Maintains the home in an optimum state of cleanliness and safety depending upon the client's resources. 3. Performs activities generally undertaken by the customary homemaker, including, but not limited to: meal preparation, laundry, grocery shopping, etc. 4. Performs casual, cosmetic assistance, such as brushing client's hair, assisting with make-up, filing/polishing nails (but not the clipping of nails). 5. Stabilizes the client when walking, as needed, by holding client's arm or hand. 6. Prepares and maintains records for billing and claims procedures. 7. Reports changes in the client's status to the RN and family member as appropriate. Sitter/Companion Services: Sitter/Companion services are provided by trained personnel who provide companionship to clients, but do not perform personal care services. Companion services are provided by a trained person who has received training in topics related to human development and interpersonal relationships, nutrition, food selection, storage and preparation, equipment and supplies, planning and organizing household tasks, and principles of cleanliness and safety. The SITTER/COMPANION: 1. Performs only those activities contained on the plan of care/assignment sheet. 2. Provides diligent observation and companionship to the client. 3. Provide medication reminders, reading, letter writing and other non-personal care tasks. 4. Provides light housekeeping tasks such as meal preparation and laundering the client's personal garments. 5. Performs casual cosmetic assistance, such as brushing the client's hair and assisting with make-up, filing and polishing nails (but not the clipping of nails). 6. Stabilizes the client when walking, as needed, by holding the client's hand or arm. 7. Prepares and maintains records for billing and claims procedures. 8. Reports changes in the client's status to the RN and family member as appropriate. Intrepid USA Healthcare Services Scope of Services Page 8 of9 2.007 Intrepid USA Healthcare Services Policy and Procedure State Specific Requirements: Texas: Texas agencies will not use volunteers in their offices or in the care of clients. Intrepid USA Healthcare Services Scope of Services Page 9 of 9 2.007 APPENDIX N Clinical Specialty Programs Clinical Specialty Programs 2006 Programs: · Congestive Heart Failure (CHF) . Chronic Obstructive Pulmonary Disease (COP D) . Diabetes Mellitus . Cerebral Vascular Accident (CV A)/Stroke Management · Hypertension (HTN) · Myocardial Infarction (MI) . Asthma . Pneumonia . Wound Care Program . Rehab/Restorative Care 2007 Programs: . Deep Vein Thrombosis . Amyotrophic Lateral Sclerosis . Parkinson's Disease . Falls Risk/Prevention Program . Peripheral Vascular Disease . Palliative/Terminal/End-of-Life Care . Pre-op Orthopaedic Services Program We f;nJ a way APPENDIX N Equal Employment! Affirmative Action Policy Intrepid USA Healthcare Services Policy and Procedure Name: Equal Employment Opportunity I Affirmative Action Section: Practices Number: 3.011 Effective Date: Revision Date: Policy Statement: This is to affirm the Companies policy of providing Equal Opportunity to all employees and applicants for employment in accordance with the applicable Equal Employment Opportunity/Affirmative Action laws, directives and regulations of Federal, State and Local governing bodies or agencies thereof. Guidelines I Procedures: 1. The Company will not discriminate against or harass any employee or applicant for employment because of race, color, creed, sexual orientation, sex, age, disability, religion, national origin, marital status, veteran status, public assistance status, and membership or activity in an organization, or any other class or status protected by applicable state or federal law. 2. The Company will take Affirmative Action to ensure that all employment practices are free of such discrimination. Such employment practices include, but are not limited to, the following: hiring, upgrading, demotion, transfer, recruitment or recruitment advertising, selection, layoff, disciplinary action, termination, rates of payor other forms of compensation, and selection for training, including apprenticeship. 3. The Company fully supports incorporation of non-discrimination and Affirmative Action rules and regulations into contracts. To this end, The Company will commit the necessary time and resources, both financial and human, to achieve the goals of Equal Employment Opportunity and Affirmative Action. 4. If an employee or applicant for employment feels he/she has been discriminated against, the employee should contact the EEO/AA Compliance Committee at the corporate office or e-mail intrepid@intrepidusa.com. Responsible parties will investigate the allegations as confidentially and promptly as possible and the Company will take appropriate actions in response to the allegations. Intrepid USA Healthcare Services Page 1 of 1 Equal Employment Opportunity / Affirmative Action 3.011 APPENDIX N HIPPA Privacy-Training Policy I Intrepid USA Healthcare Services Policy and Procedure Policy Name: HIPAA Privacy - Training Section: 1 Administration Number: 1.017 Effective Date: N1i1rch4,2003 Revision Date: March 2005 Policy Statement: The Company provides privacy training for all employees who have contact with protected health information in accordance with 45 CFR 164.530. Guidelines I Procedures: 1. All newly hired employees will receive training regarding the requirements of the HIPAA Privacy Rule as a component of their orientation. a. Home Health employee training will include a description of the Privacy Requirements as well as the Company's policies and procedures for implementation of the requirements. This training will be job specific. b. Supplemental employee training will include education on the Privacy Requirements, primarily about Reasonable Safeguards and facility policy and procedures as well as the employee requirements for compliance as a business associate per business associate addendum. 2. All members of the workforce will receive retraining if policies and procedures change and as necessary. 3. All privacy training provided to members of the workforce shall be documented by signing the Privacy and Confidentiality Agreement form. The signed Privacy and Confidentiality Agreement shall be maintained in the employee's personnel file. Intrepid USA Healthcare Services HIPAA Privacy - Training Page 1 of 1 1.017 APPENDIX N Compliance Training & Edncation Intrepid USA Healthcare Services Policy and Procedure Name: Compliance Training and Education Section: 1 Administration Number: 1.015 Effective Date: December 2003 Revision Date: 2006 Policy Statement: To ensure that all personnel are knowledgeable regarding their role in the Company's Corporate Compliance Program. Training for employees and covered contractors, in all Company businesses, will be completed within thirty days of the date of hire or contract effective date and annually thereafter. Specific training relating to standards and procedures affecting operations will be conducted more frequently in applicable areas. Communication and education regarding new laws and/or regulations will be provided as required in advance of the effective dates of the new requirements. Guideline I Procedure: 1. A standardized compliance orientation program will be provided for all new employees at the time of hire. The orientation will address, but is not limited to, the following requirements: a. The physician signature to certify care is genuine; b. Medical records are maintained in their original state and not improperly altered or fabricated; c. Items and services are billed to Medicare, Medicaid and other Federal health care programs only once, unless re-billing is appropriate; d. The circumstances for which re-billing to Federal health care programs is appropriate; e. The proper submission of cost reports; f. Compliance with Billing Policies and Procedures; g. Code of Conduct; h. Medical necessity and homebound requirement; i. Services must be provided by a qualified person; and j. Services may be billed only if actually provided. 2. Agency and CSC billing department will maintain sufficient documentation as required for payment by Medicare, Medicaid, and other Federal health care programs. 3. At least annually, (and more frequently, if appropriate) the Company will review and update, as necessary, the compliance related Policies and Procedures. 4. Within 30 days after the effective date of any revisions, new laws and/or regulations, the relevant portions of any such revised Policies and Procedures will be distributed to all individuals whose job functions relate to those Policies and Procedures. This requirement may be met by publishing the revised Policies and Procedures on the Company's intranet system with an electronic message notifying those persons whose job functions are related to the revised policies and procedures of the revisions. 5. At least annually, staff will be evaluated in their job performance. Technical, administrative processes, attendance and participation in Compliance training and education is assessed as elements in their performance evaluation. Intrepid USA Healthcare Services Compliance Training and Education Page 1 of 1 1.015 APPENDIX N In-Service Program Intrepid USA Healthcare Services Policy and Procedure P_olic:Yt-J/llTle: .. JII1_:~el"\lic:e Progr/llTl Section: 2 Care Delivery i I I I I Policy Number: 12.018 .E:ffE!_cti,!e[)/I~E!:L~~ptE!lTlbel' 1Lt~_~~_ . Revisicm Date: '. May 2006 . Policy Statement: The Company emphasizes the importance of individual development and growth through formal and informal training and in-service programs. The Company will provide in-services appropriate to the services offered by the agency and in accordance with statelfederal regulations and guidelines. A record acknowledging the employee's completion of in-services mandated by state/federal regulation will be maintained in the agency. Employees that require continuing education/in-service hours to maintain licensure/certification 'are responsible for obtaining the required hours. Guidelines I Procedures: 1. Each agency will annually develop and implement an in-service plan. Specific contenUtopics are determined based on the results of an annual assessment, employee input, direction from the administrative staff and/or Advisory Board, agency objectives, and state/federal regulations, The in-service plan is posted and maintained in the agency. 2. It is each employee's responsibility to attend in-service programs and to comply with the in-service requirement for their position 3. Staff will be required to attend in-services deemed mandatory by the agency/Company, The agency may offer additional in-services based on the staff's interests or job related topics. Mandatory in-service topics that are to be conducted annually include, but are not limited to: a. OSHA Mandatory Training' i. Bloodborne pathogens/Standard Precautions ii. Hazards Communication iii. Tuberculosis iv, Safety b. Corporate Compliance Training c. Client Rights and Responsibilities d, Emergency Preparedness e, Advanced Directives 4. In-service programs not sponsored or authorized by the agency cannot be attended during the workday without express approval of agency management 5. Home Health Aides must receive at least twelve (12) hours of in-service training, prorated according to the employee's date of hire during each tweive (12) month period. The in-service training may be provided while the aide is furnishing care to the dient 6. In-service training attendance will be recorded on a sign-in sheet 7. Contents of all in-service programs and the Identification of the presenter will be maintained in the agency for a minimum of one (1) year. * Credit for OSHA-related information attended elsewhere will not suffice in meeting the agency's OSHA requirement at hire and annually. Intrepid USA Healthcare Services In-Service Program Page 1013 2.018 Intrepid USA Healthcare Services Policy and Procedure State Exceptions: Arkansas: Arizona: Florida: Louisiana: Minnesota: Policies will be developed and enforced by the agency from participation by all personnel in appropriate employee development programs, including a specific policy on the number of in- service hours that will be required for registered nurses, licensed practical nurses and aides Personnel providing direct client care shall attend orientation and 6 hours of in-service training per year, which may include time spent in orientation. Home Health Aides and Certified Nursing Assistants must receive in-service training each calendar year which includes, a minimum of two (2) hours training, when applicable, for Home Health Aides and Certified Nursing Assistants in the assistance of clients with self- administered medications, per 400.488 F.S., HIV educational requirements per Rule 59A- 8.0185(2)(b), and to obtainlmaintain a certificate in cardiopulmonary resuscitation. Direct care staff and their supervisors must be trained in dementia care per 400.4785 F.S. The in-service sessions for Home Health Aides will include, but are not limited to: disciplinary actions, criminal background investigations, grievance proceedings, care of the body, communication, infection control, specifications of employee health and safety, payroll and documentation. Part time Home Health Aides who work the full year will be required to attend 12 hours of training. Direct care staff and their supervisors must be trained in dementia care per Minnesota Statute 144A.45, Subdivision 5. Home Health Aides and Certified Nursing Assistants, when applicable, must receive in-service training each will inciude, when applicable a minimum of two (2) hours training, in the assistance of self-administered medications, Nebraska: Agencies will provide ongoinglcontinuous and specialized training of staff to permit performance of particular procedures or to provide specialized care, whether it is part of a training program or as individualized instruction per Nebraska Administrative Code 14- 006.0401 and 14-006.0402. Rhode Island: The training for all home health aides and nursing assistants shall be prescribed as in the Rules and Regulations for the Registration of Nursing Assistants and the State Review and Approval of Nursing Assistant Training and Competency Evaluation Programs (R23-17.9-NA) of reference 13. South Carolina: Continuing in-service training programs shall be provided for all personnel to ensure understanding of their duties and responsibilities. Records of attendance and subject of program shall be maintained and retained per record retention policy. Tennessee: An educational program shall be planned and conducted for the development and improvement of skills of all the organization's personnel engaged in the delivery of home health services. Intrepid USA Healthcare Services In-Service Program Page 2 of3 2.018 Intrepid USA Healthcare Services Policy and Procedure State Exceptions continued: Texas: The Administrator and designee shall complete a minimum of six clock hours per year of continuing education in subjects related to the duties of the administrator. The in-service training program will be developed and administered by the Parent agency. The staff, including volunteers and those under contract, will be fully informed of changes in techniques, philosophies, goals, client's rights, and products related to client care. All direct care staff in agencies, licensed to provide home dialysis, must be CPR certified. Virginia: Home Health Aides may be assigned special treatments or duties, such as changing or applying non-sterile dressings or applying prescribed ointments and topical medicines, administering gastrostomy tube feedings, urinary catheter irrigations, physical and emotional needs of special case assignments, such as Alzheimer's, mental retardation, AIDS, terminally ill or newborn i~fants, assistance with urinary and bowel management programs after completion of a minimum of eight (8) hours training and demonstrated competency per Virginia Administrative Code 12VAC5-380-300. The annual in-service requirement for PCAs will be no less than 8 hours or as required by State Programs and the annual requirement for homemaker/chore workers will be 4 hours. Intrepid USA Healthcare Services In-Service Program Page 3 of 3 2.018 APPENDIX N Corporate Compliance Program Intrepid USA Healthcare Services Policy and Procedure P()lic:yt:4CiI11El: '.. Lc:;()~poratec:;ol11plianceF'rogral11 I.. Section: 1 Administration Policy Number: .1.039.... Effective Date: December 2003 , Revision Date: iEElI>~lJary200~ Policy Statement: The Corporate Compliance Program is the Company's commitment to full compliance with all Federal health care program requirements. The program outlines the principles and responsibilities to continually monitor a comprehensive billing compliance program. The Company will consistently act In accordance with laws and regulations and any Corporate Integrity Agreements applicable to billing for services under Federal health care programs. Guideline I Procedure: 1. The Compliance Program will apply to all home health and supplemental staffing agencies, employees and contractors for which the Company directly or indirectly has management responsibility, regardless of whether an agency is owned by the Company or operated pursuant to a management agreement 2. The Company has established a Corporate Compliance Committee. The Corporate Compliance Officer chairs the Committee. Representatives from each functional area at CSC will be appointed to attend the meetings. 3. The purpose of these meetings is to share information, provide ongoing guidance to the Compliance Program, review monitoring activities within the Company offices, and to meet the requirements of any Corporate Integrity Agreement 4. The Corporate Compliance Officer's responsibilities shall include, without limitation: a. Developing and implementing policies, procedures and practices designed to ensure compliance with the requirements of the Corporate Integrity Agreement and Federal health care program requirements; b. Make periodic reports, at least quarterly, on compliance matters to the Board of Directors; c. Implementation of the Compliance Program; d. Monitor day to day compliance activities related to the Program; e. Investigation or the arrangement for the investigation of perceived non-compliance; and f. Reporting to the Compliance Committee on the status of compliance and compliance activities. 5. The Corporate Compliance Committee's responsibilities shall include, without limitation: a. Support the Corporate Compliance Officer in fulfilling his/her responsibilities; b. Regularly reviewing compliance activities carried out during the previous calendar quarter and assist in planning for compliance activities to be carried out in the upcoming quarters; c. Consulting with the Corporate Compliance Officer regarding both general and specific matters which may require attention; d. Reviewing and updating, at least annually, the content of the Program to ensure the integrity of the Program is maintained; and e. Ensuring that policies are consistent with the general principles of the Company's billing compliance and the Code of Conduct. 6. The Regional Director of Operations responsibilities shall include, without limitation: a. Stay informed on requirements relating to billing for services furnished by the agencies; Intrepid USA Healthcare Services Corporate Compliance Program Page 1 of 2 1.039 Intrepid USA Healthcare Services Policy and Procedure b. Inform agency data entry/billing personnel (or contractors) of changes in billing requirements; c. Engage in monitoring activities as directed by the Corporate Compliance Officer; and d. Assure the orientation for all new employees, and contractors for the agency pertaining to compliance. 7. The Manager/Administrator is accountable for: a. Implementing and maintaining the Corporate Compliance Program; b. Convening periodic meetings of the local Quality Committee; and c. Reporting on the status of compliance and compliance activities to their Regional Director of Operations and the Corporate Compliance Officer. 8. All employees and contractors are required to promptly report any good faith belief of non-compliance with the Program, any Corporate Integrity Agreement or regulations associated with participation in Federal health care programs. An employee or contractor may report verbally or in writing to his/her supervisor, to the authorized individuals responsible for receiving such reports, or through Intrepid ALERT (the toll free disclosure line). 9. Response and Prevention: Mechanisms to address verified instances of non-compliance may include: a. Review of existing standards and procedures to determine the need for any modifications or additional procedures or process improvements; b. Additional employee training as needed; c. Self-reporting of non-compliance to appropriate governmental authority; and d. Repayment of any overpayments that have been received inappropriately by the Company from the Medicare or Medicaid program. 10. Enforcement and Discipline: The Program will be consistently enforced through appropriate sanctions and disciplinary measures when violations are identified and employee culpability is established. Employees will also be subject to discipline for failing to participate in organizational compliance efforts. Enforcement measures will be determined based on the severity and nature of the violation Intrepid USA Healthcare Services Corporate Compliance Program Page 20f2 1.039 II i Ii Ii I I I I Ii " Ii I I \ APPENDIX N Admissions Policy Intrepid USA Healthcare Services Policy and Procedure Name: Admission Section: 2 Care Effective Date: 1 1999 Number: 2.001 vision Date: October 2006 Policy Statement: Acceptance of a client for services will be based on a reasonable expectation that the specified needs of the client can be adequately met by the agency. Environmental conditions in the home will be conducive to the adequate treatment of the client and the safety of both the staff and client. Clients that do not meet the criteria for admission will receive communication regarding the reason for non-admission. If applicable, the client will receive an Advance Beneficiary Notice in accordance with Medicare's guidelines. The agency will provide services to accepted clients without regard to race, color, diagnosis, sex, sexual orientation, marital status, age, religion, creed, national origin, citizenship status, physical or mental handicap or disability or as otherwise required by state or federal law. Guidelines I Procedures: 1. The agency will not accept clients whose care needs are determined to be beyond the scope of services that can be provided by the agency. Services and care will conform to current professional and community standards of practice for the respective discipline(s). Clients will be referred to alternative services, if available, when the agency is unable to meet identified client needs. 2. The client must reside within the geographical area served by the agency. 3. The agency may accept Medicare, Medicaid (or equivalent state sponsored health plan), private insurance, private pay, worker's compensation, Veterans Administration, and vocational rehabilitation as a primary payment source(s) for home care. 4. The agency does not provide care to clients with no third party payor source or without the ability to pay for home care services except as approved by the RVP. * Criteria for Admission: 1. Requests for skilled services and orders for care are accepted from physicians who hold a current valid state license. The physician's plan of treatment will include orders for all services except housekeeping or companion services unless such orders are required by the state or payor source. 2. There is a reasonable expectation that the client's specified needs can be met, including a plan to meet medical emergencies. 3. Upon receipt of the referral, the client will be admitted within 24 hours unless otherwise directed by the physician, referral source, client, or payor. The reason for the delayed admission will be documented in the clinical record. 4. The client must identify an available, willing and able primary caregiver who is able to oversee the needs of the client in the emergent event that the Company staff is unable to be on-site to provide services. * Agencies will meet requirements regarding the provision of indigent care specified by any license, certification, or contractual requirement. Intrepid USA Healthcare Services Admission Page 1 of 2 2.001 Intrepid USA Healthcare Services Policy and Procedure State Specific Requirements: No. Carolina: The agency ensures available back up staff for clients receiving CAP MRIDD services when the lack of immediate care poses a threat to the recipient's health and welfare. If informal providers and agency back up staff is unavailable, the agency will document who provided services, support, and care in the absence of direct service employee. Texas: Agency staff members will implement, enforce and educate, all clients 60 years of age and older regarding the provisions of Human Resources Code, Chapter 1 02-Rights of the Elderly. Virginia: It shall be the responsibility of the health care provider to inform clients of the below provision prior to proViding him with health care services, which create a risk of exposure. Whenever any health care provider, or any person employed by or under the direction and control of a health care provider, is directly exposed to body fluids of a client in a manner which may, according to the then current guidelines of the Centers for Disease Control, transmit human immunodeficiency virus or hepatitis B or C viruses, the client whose body fluids were involved in the exposure shall be deemed to have consented to testing for infection with human immunodeficiency virus or hepatitis B or C viruses. Such client shall also be deemed to have consented to the release of such test results to the person who was exposed. Intrepid USA Healthcare Services Admission Page 2 of 2 2.001 , Ii !i " I! I I I I .'l Ii' APPENDIX N Recruitment Program , I' ]i 'il IT , I I I Ii II " II' il I I II I I: , I I I: i I i I I II Ii , Intrepid USA Healthcare Services Policy and Procedure . Policy Name: ResrlJitlll~nt, .lnt~ryie1Ning ,.l-iirillgCiIl~..~etention Section: 3 i E:lIlpl()Ylllent erCic:tices ; Policy Number: 3.013 Effective Date: ay 2006 I Revision Date: Policy Statement: The Company will recruit, hire and retain employees using consistent practices and processes, in compliance with all state and federal requirements. Recruitment: The Company will use several means to recruit employees. All recruitment efforts are aimed towards recruiting a diverse, competent and skilled workforce. The following recruitment options include but are not limited to: 1. Posting on the Company's Website and other website postings 2. Print advertising to local publications and newspapers 3. Job fairs 4. Open houses in Agency 5. School recruiting 6. Recruiting to diverse groups in accordance with our Affirmative Action plan 7. Employee referral 8. Sign -on bonuses InterviewinQ and HirinQ: 1. Prior to beginning recruitment for a new or vacant position, all applicable forms, including Personnel Requisition forms must be approved by RVP. Requisitions for full time positions are forwarded to Corporate Human Resources when approved. 2. All applicants must complete an application form prior to or at the time of the interview. Applicants must meet minimum qualifications as noted on the job descriptions. If the applicant does not meet minimum qualifications but has other experience that qualifies them for the position, the RVP must approve. This exception is noted with separate documentation and placed in the personnel file if the applicant is hired. 3. When interviewing a prospective job applicant, the hiring manager may only ask questions which reasonably relate to the job in question; and all applicants are asked similar questions. The hiring manager will not request information that is not job related or that might reveal an applicant's protected status (e.g., disability, religion, race). Staffs are selected based on education, experience, qualification, communication and interpersonal skills and other skills required for the job. 4. During the interview, the hiring manager will share the job description, job expectations, and the applicant benefits summary. 5. If the hiring manager would like to offer a position, it may be done prior to receiving all background checks, depending on applicable state law. This employment offer is contingent The applicant is informed that the contingent offer may be revoked if any results are not acceptable. Intrepid USA Healthcare Services Recruitment, Interviewing, Hiring and Retention Page 1 of 2 3.013 Intrepid USA Healthcare Services Policy and Procedure 6. See personnel file checklist for all applicable new hire paperwork. maintained in a separate file as are Affirmative Action and 1-9s. All confidential. All employee health records are aspects of the personnel file are Retention: 1. To retain employees, employees are treated fairly with consistent application of all policies, procedures and compensation practices. 2. The Company values employees with experience and knowledge. Employees who are high performers and with the necessary qualifications are considered for promotion first before seeking outside candidates. Rehire: 1. Depending on the circumstances, The Company may consider a former employee for re-employment. Such applicants are subject to the Company's usual pre-employment procedures. 2. To be considered, an applicant must be in good standing at the time of their previous termination of employment with the Company. Intrepid USA Healthcare Services Recruitment, Interviewing, Hiring and Retention Page 2 of 2 3.013 APPENDIX N Intrepid University At Intrepid. we are committed to providing quality educational opportunities to our employees. We think that investing in continuing education and learning opportunities to enhance your clinical and administrative growth and knowledge is the right thing to do. To that end, we are excited to offer a unique and innovative opportunity to receive CEUs and meet mandatory in-service requirements online, utilizing Intrepid University'. Online courses and in~services meet federal, state and accrediting body requirements. And, you can take as many courses as you want at absolutely no cost to you! This benefit is now available to all full-time and regular part.time employees. Take full advantage of the best online learning system available. Visit Intrepid University often! As we continue our pledge to support our staff, encourage their growth and provide them with opportunities to make a difference in the world, we commit to education as a vehicle to invest in our resources and ultimately become the Premiere Provider and Employer of Choice. THIS PAGE IS SECURE - you may !J>:!-t il me.ss.lfJe from your hH,wsel letting .you know tt.,'lt you ,He le,1ving a s.e{,;Hl'e Il.liJe. It"s OK - did" Ycs. . I intrepid Your USERNAME is: INT+ your employee number Note: Find your employee number listed as 'EMP No/Dept" in the top left corner of your Intrepid pay stub Example: INT00345345 (no spaces) Your PASSWORD Is: Your Home Zip Code I Login Us.",.me ,Student 10111 I Password ! J t___ _____ _ ___ .._,.~~~-_..".__.__._. I Mailing Company II I I * Mailing Address 1113456 Smart Street I Mailing Address 211 I * Mailing City liT occoa I * Mailing State I ~ * Mailing Conntry Ilus I * Mailing Zip 1112345 Ij I Phone Number Guide So we can contact you if there is a problem Area Code (3 digits) - Number (3 digits - 4 digits) - EKtension (Up to 10 digits) Home Phone Number 11838 fll83 fl1234 fl I ext I Daytime Number II fl fl fl I ext I I Fax Number II fl fl fl len I ASHA Number 1111 you have one! I For SLPiAUD * How did you heal about Care2Learn Ilwork I Ql ~Ql .!: .- = Ql Ql (.).- tIl ... C. Ql- = (Ill -- c..2- Ql ... (.) tIl (.) (.) (/l .~ Ql-~ .- ...J Ql 0 tIl-= tIl (Ill = ..2l Ql (.) C. .- ...J ..... Ql .: ... p tIl .- Ql .!: c. .- (.) .~ -= := ;~..I 0, N :.: " III > ~ ~ CI ~",~g~...'.c..... iri ". c"'~ O. 'lI!-: CE HOllrs Price Objectives i IView File in New Window Ontline r;!l 411'Df" AUt/101 1 Bio IView File in New WiIl(IIlW Cour.se Narne Description Product ID CE Hours Price A Stud), of the Grief Process for Heant. Professionals This course looks at the grief process and explores what to look for in our patients and in ourselves. This course was modified on 7/21/03. 1107 2.4 $33.60 Welcome Intrepid CE Demo CUlTent Courses Previous Courses Edit Profile Hell) Desk Ilogout Cart I CEU Tracker Attending Course; Dealing With Difficult People 11 12 I 3 I 4 I 5 16 17 18 I 9 110 I Move from ~e to page in the co rse. ~ k H . B k . kTI.P~ Will open to the bookmarked page IC ere to 00 mar liS age . next time you open the course. Title of Activity: Dealing With Difficult People Ready to take the test? Total Number of Contact Hours: 1 Intended Level of Learner: Introductory Got a question for the author? - This will contact the author via email. I Obj""'" II Conte,. I Di scover how to tell if a Bad days do happen: person is being difficult --Traits of difficult person or just having a bad --Traits of person having bad day day Why do they act that way? Four tvoes of diffi cult oeoole Teaching/Learning Resources Written material online Posttest questions MASTER FilE Rhonda M.. Medows, MD,.Commissioner. . Sonny Perdue, Governor 2 Peachtree Street, NW . Atlanta,GA 30303-3159 www.dch:georgia.gov December 18, 2006 NewellD. Yarbaraugh, Jr. Yarboraugh Cansulting,Inc. 103 Marsh Edge Lane Savannah, Geargia 31419 RE: Praject Number: GA. 2006-131 Establish New Home 'Health AgenCy in SSDR 8 . Dear Mr. Yarbaraugh: This carrespandenc~isin referenceta theCertiflcate afNeedprajects that arejoined i~the current hame healthbatching cycle for StClteService Delivery Regian (SSDR)8. As required ,by Ru/el11-2-2-.08(lJ(g). . all applicants far .aCertificate of Need. are provided, an .or . before the . sixtieth.(60) day ofevaluatian; tile .opportunity tameet with staff .of the Department of Community Health, Division. of Health Planning,. in .order tadiscussissues that cOuld patentially'result in the denial of,ana'pplieation. . .The 60th day aft:hebatching review cycle 'faryaur praject is January 12, 2007. . A60~day.meeting has been sch,eduledfar Thursday, January, 11 at 10:00,a.in. The meeting should last appraximately .one haur. Staff from the Division of Health Planning will beili attendance to d.iscu~s your C1Pplicatianwithyau and/ar a representative(~) faryaurarganizatian. ' . Ifyauhave anyquestians regarding the farthcaming meeting) please cantac:tme at (404) 463-1101. Sincerely, , )Lb.JJ~' . ..., i Karesha. Berkel MSHSA H'1"lth ~ystems ..l1;llyst I - Equal Opportunity Employer ~ MASTER filE Rhonda M Medows, MD, Commissioner 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Sonny Perdue, Governor CERTIFICATE OF NEED SIXTY DAY MEETING BATCHED PROJECTS FOR HOME HEALTH AGENCIES IN SERYICRDELIVERY REGION 8 , GA.2006~130,GA.2006-131~ JANUARY iI, 2007 10:00 A.M. AGENDA I. PURPOSE Rule 111-2-2-.07(1)(g): Ifduring the first 2months of the review of the application the Departmentfinds there are factors that create a potential for denial of the application" the Department shall, on or before the sixtieth day of the review period, provide the applicant an opportunity to meet with the Department. The problems with the application will be described and an opportunity offered to amend or withdraw the application or to submit additional information. Such additional information must be submitted prior to the seventy-fifth day of the review period. " II. DESCRIPTION OF PROJECTS AND PRELIMINARY EVALUATION ISSUES The Georgia, Department of Community. Health, Division of Health Planning, issued a Batching Review Cycle Notification for Home HealthAgencies on September 14, 2006 (revised November 2, 2006) which identified a total unmet need for 515 patients in Service Delivery Region ("SSDR") 8. In response, three (3) applicants submitted requests to, the 'Georgia Department of Community Health, Division of IIealth Planning, for issuance of Certificates of Need for new or expanded home health agency in the service area. Each of these' applicants is described below: , GA;2006-130 AmedisysHome Health of Macon has requested a Certificate of Need to expand its home health agency into the following Counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Stewart, , Sumter and Talbot. These Counties show a need for 621 patients. Amedisys currently serves Taylor, Schley and Muscogee counties in SSDR 8; The total estimated cost for the proposed project is $125,000. General Review Considerations . Rule111~2-;2~.09(1)(a) Rule 11l-2-2-.09(1)(d) Rule 111-2-2-.09(1)(g) Consistency with State Health Plan Financial Feasibility Financial and Physical Accessibility . . Home Health Addendum . Rille 111-2-2-.32(3)(d) . Rule 111-2-2-.32(3)(j) . Rule, 111-2-2-.32(3)(1) Community Linkages Accreditation Financial Accessibility Equal Opportunity Employer .- SSDR 8 Home Health Services Batching Sixty Day Meeting Agenda January 11, 2007 Page 2 . GA.2006-131 Intrepid USA Healthcare Services, Inc. has requested a Certificate of Need to establish a new home health agency to serve the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, . Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has ; a total estimated cost of $70,000. General Review Considerations · Rule 111-2-2-.09(1)(a) · Rule 111-2-2-.09(1)(d) · Rule 111-2~2-.09(1 )(g) Consistency with State Health Plan Financial Feasibility Financial.& Physical Accessibility Home Health Addendum · Rule 111-2-2-.32(3)(d) · Rule 111-2-2-.32(3)(1) Community Linkages Financial Accessibility , GA.2006-132 . United Home Care of South West Georgia, Inc. has requested a Certificate of Need to establish a new home 'health agency to service the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The :project has a total estimated cost of $22,363. I :General Review Considerations · Rule 111-2-2-.09(1)(a) · Rule 111-2-2-.09(1)(d) · Rule 111-2-2-.09(1)(g) Consistency with State Health Plan Financial Feasibility . Financial & Physical Accessibility Home Health Addendum · Rule 111-2-2-.32(3)(1) Financial Accessibility III. DEADLINES CD Additional Information Deadline CD Letters of Support/Opposition I>eadline CD Amendments/Opposition Responses Deadline CD Decision Date January 26, 2007 February 6, 2007 March 3, 2007 March 13, 2007 MASTER FILE Rhonda M Medows, MD, Commissioner Sonny Perdue, Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 . www.dch.georgia.gov CERTIFICATE OF NEED SIXTY DAY MEETING BATCHED PROJECTS FOR HOME HEALTH AGENCIES IN SERVICE DELIVERY REGION 8 G~.2006-130JGA.2006-131 GA.2006-132 JANUARY 11,2007 lO:OOA.M. AGENDA I. PURPOSE Rule 111-2-2-.07(1 )(g): If during thefirst 2 months of the review of the application the Department finds there are factors that create a potentialfor denial of the application, the Department shall, on or before the sixtieth day of the review period, provide the applicant an opportunity to meet with the Department. The problems with the application will be described and an opportunity offered to amend or withdraw the application or to submit additional information. Such additionalinformation must be submitted prior to .. the seventy-jifth day of the review period. II. DESCRIPTION OF PROJECTS AND PRELIMINARY EV ALUA TIONISSUES The Georgia Department of Community Health,. Division of Health Planning, issued a. Hatching Review Cycle Notification for Home Health Agencies on September 14,2006 (revised November 2,2006) which identified a total unmet need for 515 patients in Service Delivery Region ("SSDR") 8. In response, three (3) applicants submitted requests to the Georgia Department of Community Health, Division of Health Planning, for issuance of Certificates of Need for new or expanded home health agency in the service area. Each of these applicants is described below: GA.2006-130 Amedisys Home Health of Macon has requested a Certificate of Need to expand its home health agency into the following Counties: Chattahoochee, Clay, Harris; Macon, Marion, Quitrnan, Randolph, Stewart, Sumter and Talbot. These Counties show a need for 621 patients; Amedisys currently serves Taylor, Schley and Muscogee counties in SSDR 8. The total estimated cost for the proposed project is $125,000. General Review Considerations . Rule 111-2-2-.09(1 )(a) Rule 111-2-2-;09(1)(d) Rule 111-2-2-.09(l)(g) Consistency with State Health Plan Financial Feasibility Financial and Physical Accessibility . . Home Health Addendum · Rule III ~2~2-.32(3)(d) · Rule 111-2-2-.32(3)(j) · Rule 111-2-2-.32(3)(1) Community Linkages Accreditation Financial Accessibility Equal Opportunity Employer .- .. SSDR 8 Home Health Services Batching Sixty Day Meeting Agenda January 11, 2007 Page 2 GA. 2006-131 Intrepid USA Healthcare Services, Inc. has requested a Certificate of Need to establish a new home health agency to serve the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of $70,000. General Review Considerations · Rule 111-2-2-.09(1)(a) · Rule 111-2-2-.09(1)(d) · Rule 111-2-2-.09(1)(g) Home Health Addendum · Rule 111-2-2-.32(3)(d) · Rule 111-2-2-.32(3)(1) Consistency with State Health Plan Financial Feasibility Financial & Physical Accessibility Community Linkages Financial Accessibility GA.2006-132 United Home Care of South West Georgia, Inc. has requested a Certificate of Need to establish a new home health agency to service the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of$22,363. General Review Considerations · Rule 111-2-2-.09(1)(a) · Rule 111-2-2-.09(1)( d) · Rule 111-2-2-.09(1)(g) Home Health Addendum · Rule 111-2-2-.32(3)(1) III. DEADLINES Consistency with State Health Plan Financial Feasibility Financial & Physical Accessibility Financial Accessibility CD Additional Information Deadline CD Letters of Support/Opposition Deadline CD Amendments/Opposition Responses Deadline CD Decision Date January 26, 2007 February 6, 2007 March 3, 2007 March 13, 2007 Rhonda M Medows, MD, Commissioner Sonny Perdue, Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov BATCHED CERTIFICATE OF NEED HOME HEALTH PROJECTS . ~f30--; Amedisys Home Health of Macon GA 2006:131'1 Intrepid USA Healthcare Services GA 2006-132. United Home Care of SW Atlanta SSDR 8 SIXTY-DAY MEETING THURSDAY, JANUARYll,2007 10:00 A.M. ATTENDANCE SHEET Please sign your name below to indicate your attendance. Thank you. Pt2~.J.f- ~ S\A- \ \Iv OJ\!\. (jrnsuj ti v\ /1~~ Equal Opp nity Employer .j' .' SSDR 8 BATCHED HOME HEALTH PROJECTS ATTENDANCEFORM~AGE2 JANUARY 11,2007 . . ~ GEORGIA DEP...ltl'MIUrr OF 1:' COMMUNITY He:.U.Tn \ ("' Georgia MASTER FILE f<ll Certificate of Need, f j Amendment Request --- -'J WENTER the Project Number and County below for the project that you are amending. Use the Format YYYV-###. DA TE STAMP PROJECT NUMBER rl5) ~ [: ~ nne ~ UI} MAR 0 2 2007 l0 GA 2006 - 131 DIVISiON OF HEALTH PLANNING COUNTY: Sumter Signed Original and 1 Copy Fee Verified rjtiJ (This Box for Division of Health Planning Use Only) Name of Applicant: Intrepid USA Healthcare Services (F. C. of Georgia, Inc.) General Information: 1. This Amendment Request form is a required document that must be submitted by an Applicant wishing to amend its application. An amendment is a revision to the original application submitted to the Department or to any additional information submitted by the Applicant. 2. Please review this form before attempting to complete and submit the information requested. 3. This form must be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 4. All form fields must be completed. If a field is not applicable, so indicate. 5. Attach you revised or supplemental amendment information to this form. 6. This amendment request must be submitted to the Department no later than 10 days before the end of the review cycle. Applicants must submit a signed original and one (1) copy of this Amendment Request and any and all attached documentation. 7. The signed original Amendment Request and the single copy must be submitted on loose leaf, one-sided 8 'I:z by 11-inch paper only. The 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. 8. 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. State of Georgia: Certificate of Need Amendment Request Form CON 103 Revised September 2006 Page 1 SECTION A. IDENTIFYING INFORMATION 1. Please identify the Applicant. APPLICANT Applicant Legal Name: F. C. of Georgia, Inc. d/b/a (if applicable): Intrepid USA Healthcare Services Address: 6600 Frances Avenue South, Suite 510 City: Edina State: MN I Zip: 55435 County: Hennepin Main Business Phone: 952-285-7300 2. Please identify the person to whom the Department may address questions regarding this amendment. CONTACT PERSON Name: Newell D. Yarborough, Jr. I Title or Position: Consultant Address: 103 Marsh Edge Lane City: Savannah State: GA I Zip: 31419 Phone: 912-925-5896 I Fax: 912-925-0107 E-mail Address: ndy@aol.com SECTION B. AMENDMENT DESCRIPTION 3. Indicate the type of applicable amendment(s). Check all that apply. D Change in Scope, e.g. change in beds or services D Change in Owner of Legal Applicant D Change in Physical Location or Space Capacity D Change in Costs or Charges D Change Commitments to Indigent and Charity Care [gJ Other: Change in signatory State of Georgia: Certificate of Need Amendment Request Form CON 103 Page 2 Revised September 2006 4. Briefly explain the nature of the amendment. Attach all amended documentation, forms (e.g. pro forma), etc. Change in the contact person, authorized representative and an amended signature page. State of Georgia: Certificate of Need Amendment Request Form CON 103 Revised September 2006 Page 3 SECTION C. ADDITIONAL FILING FEE If the estimated project costs are increased by this Amendment Request, the Applicant must submit an additional filing fee as calculated in the table below. Any such filing fee shall be made payable to the "State of Georgia" and shall be remitted by Certified Check or Monev Order and included with the submission of this form. ADDITIONAL FILING FEE 1. Has this Amendment Request increased the Total Cost Applicable to Filing Fee? DYes If YES + Complete this Table [8J No If NO + Do not complete the remainder of this Table. No additional filing fee is due. 2. Enter Total Cost Applicable to Filing Fee from oriqinal application $ (From Line 16, Question 22, Page 13) 3. Enter Total Cost Applicable to Filing Fee from this Amendment $ (From Amended Line 16, Question 22, Page 13) 4. Subtract Line 2 from Line 3 $ 5. Multiply Line 4 by .001 $ 6. Enter the amount of Line 5 or $500, whichever is greater. $ 7. Have you submitted a Certified Check or Money Order made payable to "State of Georgia" DYes for the amount listed in Line 6 above? DNo SECTION D. CERTIFICATION OF APPLICANT By signing below, a) I hereby certify that the contained statements and all attachments hereto are true and complete to the best of my knowledge and belief and that I possess the authority to submit this Amendment Request and bind the Applicant to promises made herein; b) I further understand that if issued a Certificate of Need, the Applicant is- bound to any representations that have been made within this Amendment Request and any and all documentation attached hereto; and c) 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. Signature of Authorized Signatory (BLUE INK ONLY): ate: 2/26/07 Name: Newell DYarborough, Jr. Title: Consultant Submitto: Division of Health Planning Department of Community Health 2 Peachtree Street, NW - 5'" Floor Atlanta, GA 30303 State of Georgia: Certificate of Need Amendment Request Form CON 103 Revised September 2006 Page 4 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: F. C. of Georgia, Inc. d/b/a (il applicable): Intrepid USA Healthcare Services (Intrepid USA) Address: 6600 Frances Avenue South, Suite 510 City: Edina State: MN I Zip: 55435 County: Hennepin Main Business Phone: 952-285- 7300 Parent Organization: CONTACT PERSON Name: William Edwards I Title or Position: COO Phone: 952-285-7328 I Fax: 952-285-6325 E-mail Address: BEdwards@intrepidUSA.com 2. Is the name of the lacility or proposed faCility different than the Applicant's legal name? IZJ YES ONO If YES -+ 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 -+ Continue to the next question. FACILITY Facility Name: Intrepid USA Healthcare Services Facility Address: 1610-0 East Forsyth Street (For initial verification of site only) City: Americus State: GA I Zip: 31709 County: Sumter I Phone: 229-430-8878 3. If the facility is currently existing, is it currently licensed or permitted by the Department of Human Resources? IZJ YES ONO o Not Applicable IIYES -+ 0 Attach a copy of any and all licenses and permits at APPENDIX B. IINO-+ Continue to the next question. II Not Applicable -+ Check one of the following: o Not Currently Existing (Proposed Only) o No License or Permit Required State of Georgia: Certificate of Need Application Section 1 Form CON 100 Page 1 Revised September 2006 10. Does the Applicant have Legal Counsel to whom legal questions regarding this application may be add ressed? [2J YES D NO If YES -+ Identify the lead attorney below. If NO -+ Continue to the next question. LEGAL COUNSEL Name: Clyde L. Reese, III Firm: Reese & Hopkins, LLC Address: 84 Peachtree St., NW, Suite 600 City: Atlanta I State: GA I Zip: 30303 Phone: 404-658-6088 I Fax: 404-658-6089 Email: CReese@reesehopkinslaw.com 11. Did a Consultant prepare and/or provide information in this application? If YES -+ Identify the Consultant below. If NO -+ Continue to the next question. [2J YES D NO CONSULTANT Name: Newell D. Yarborough, Jr. Firm: Yarborough Consulting, Inc. Address: 103 Marsh Edge Lane City: Savannah I State: GA I Zip: 31419 Phone: 912-925-5896 I Fax: 912-925-0107 Email: NDY@AOL.COM 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? [2J YES D NO If YES -+ 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 -+ Continue to the next question. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 5 AUTHORIZED REPRESENTATIVE Name: NeweIID.Yarborough, Jr. Firm: Yarborough Consulting, Inc. Address: 103 Marsh Edge Lane City: Savannah Phone: 912-925-5896 Email: ndy@aol.com Zip: 31419 Fax: 012-925-0107 rJr 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? DYES [8J NO If YES -+ 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 -+ Continue to the next question. LOBBYIST DISCLOSURE STATEMENT Affiliation with Registered with Name of Lobbyist Applicant State Ethics Commission? D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page 6 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. Sign / ~, APPLICANT CERTIFICATION (BLUE ONLY): ~~. Name: William Edwards Title: COO Date: 2/21/07 State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Applicant Certification Page 37 Intrepid USA Healtheare Services Response to Opposition Comments United Home Care of South West Georgia (2006-132, Contained in Opposition Form Filed) ISSUE: Rule 111-2-2-.06(2): Submittal of Applications RESPONSE: As a threshold matter, the CON application for Intrepid was properly deemed complete for review. Mr. William Edwards, COO of Intrepid, engaged the services of Mr. Yarborough to prepare and submit the CON application to establish a home health agency in SSDR 8. Mr. Yarborough has acted in conformance with this authorization by prepariug, submitting, and signing the application, responding to inquiries from the Division of Health Plarming, attending the 60-day meeting, preparing, signing and submitting the additional information, preparing, signing, and submitting opposition responses. Mr. Yarborough will continue to prepare and sign any amendments and responses as may be necessary during the review of the Intrepid's CON application. This issue was not cited during the 60-day meeting. For purposes of this CON application, Mr. Yarborough is authorized as the applicant's signatory. Attachcd to this response is a letter from Mr. William Edwards, which confirms that Mr. Yarborough is the authorized contact (Exhibit I); and, an amended pages one, five, six, and 37 which will clarifY the authorization (note that these documents are attached to the Amendment Request form). ISSUE: Rule 111-2-2-.09(1)(0): Consistency with the State Health Plan RESPONSE: Intrepid addressed the project's consistency with the State Health Plan on Page 10 of the original application. The service-specific rules were addressed on Pages 36.1 through 36.15. ISSUE: Rule I I I-2-2-.09(I)(b): Needfor the Proposed Project Rule 111-2-2-.32(3)(B): Needfor a New or Expanded Home Health Agency "...Intrepidfails to document and describe in detail its various proposed service offerings, specific disease management tools, or specific corporate programs and services that it will bring to the counties it proposes to serve. " RESPONSE: Intrepid included a scope of services document in Appendix N of the original application which describes the proposed services to be provided. Included in this same Appendix, is a document that lists the clinical specialty programs that will be provided. In the 60 day meeting response, Intrepid discussed clinical program offerings such as a wound care V AC. Exhibit 2 of this document again listed Intrepid's clinical specialty programs. Additional information on the proposed clinical programs is attached as Exhibit 2. "...Intrepid fails to provide any documentation of efforts made to date or plans to develop community linkages within SSDR 8. " RESPONSE: Intrepid provided an extensive discussion of community linkages, along with numerous letters of support. ISSUE: Rule I 11-2-2-.09(I)(d): Financial Feasibility "... there are insufficient fUnds presented in the project costs to develop a new office. " RESPONSE: Start-up costs were identified for each line item on page 3 of the 60 day meeting response and includes building rent~ utilities, janitorial services, communications/telephone, office supplies, postage and salaries/fringe benefits. ISSUE: Rule 111-2-2-.09(I)(g): Financial Accessibility Rule 111-2-2-.32(1): Financial Accessibility "Intrepid does not project any self pay charges for the agency in the second year of operation, yet Intrepid proposes to write off$61,944 in indigent/charity care. Intrepid has not indicated how it will meet its commitment to indigentlcharity care operationally and has not provided for any non-clinical or clinical staff to assist in these efforts. " RESPONSE: Self pay patients are very uncommon for a Medicare certified home health agency since the vast majority of these patients seek nursing services from a private duty agency whose costs are much lower than a certified agency. Self pay patients were included in the "Insurance/Private Pay" category (please note that the applicant considers "self pay" and "private pay" to be interchangeable terms). The plan to meet the indigent/charity care commitment was contained in Intrepid's 60 day meeting response. Intrepid plans to use the Federal Poverty Guidelines as a basis for determining Indigent/Charity patients and the Agency Administrator will provide operational oversight of the Indigent/Charity care commitment. Furthermore, the only source of bad debt in a Medicare certified home health agency is commercial insurance/private pay patients. If private pay patients do not pay their bill in full, they will be classified as bad debt, not indigent/charity care. ISSUE: Rule II 1-2-2-. O9(e): Effects on Payors Rule 111-2-2-.32(m): Comparable Charges RESPONSE: The proposed charges supplied by Intrepid are estimates prepared by an accountant who specializes in Medicare certified home health reimbursement and were based on the applicant's latest filed Medicare cost report (please refer to the pro forma assumptions contained in Appendix G of the original application). Please note that as of October 1999, the Center for Medicaid and Medicare Services (CMS) issued proposed regulations for a Prospective Payment System which became effective for all Medicare-certified home health agencies on October I, 2000. The regulations establish payments based upon episodes of care. An episode is defined as a length of care up to 60 days with mutiple continous episodes allowed under this rule. Episode payments are made to providers regardless of the costs or charges to provide care which effectively renders charges moot. ISSUE: Rule 111-2-2-.09(h): Positive Relationship with Healtheare Delivery System [sic] "Intrepid provides little evidence of existing relationships or proposed community linkages within SSDR 8. " RESPONSE: Intrepid filed additional documentation of community linkages along with support letters from SSDR 8 after the initial application was filed. ISSUE: Rule 111-2-2-.09(1): Clinical Needs of Health Professionals Rule 111-2-2-.32(h): Ability to Recruit and Retain Qualified Staff RESPONSE: Page 33 of the original application documents Intrepid's commitment to serve the needs of clinical training programs. Recruitment and retention issues were addressed in the original application. Furthermore, an Administrator for the proposed agency along with a Physical Therapist have already been hired. Amedisys Georgia, LLe d/b/a Amedisys Home Health of Macon (2006-130, Contained in Amedisys' 60 day meeting response) ISSUE: Audited Financials RESPONSE: As stated in the original application, Intrepid does not have audited financials. Documentation of the availability of funds were provided in the original application and in the 60 day meeting response. ISSUE: Disease Management Program RESPONSE: Please refer to Exhibit 2. 2 "Clinical Pathways are an interdisciplinary plan of care that outline the sequence and timing of clinical interventions for professional staff caringfor specific groups of patients. Intrepid Home Health Services has established standardized clinical specialty programs based on defined protocols to address the acute and palliative care requirements of large groups afpatients with similar diagnoses. We believe that careful adherence to these protocols enables Intrepid to produce consistent and measurable clinical outcomes for patients and payers in all of its locations. Terms such as "Care Maps, Care Steps and Critical Pathways" are used interchangeably to describe clinical pathways. The goals for clinical pathways are to provide optimal patient care, enhance satisfaction for the patient and family/caregiver, and manage the episode of care with appropriate visit utilization. There are many advantages to using clinical pathways over traditional home care documentation. At the staff level, pathways enhance the understanding of home care services, foster effective episode management, improve documentation, increase coordination of patient care, and increase interdisciplinary communication. At the management level, pathways "equalize" staff to some degree, regardless of education, and improve identification of staff education needs. Administrators benefit from pathways as they enhance resource utilization, aid in program development, improve patient outcomes and support clinical excellence and compliance initiatives. "SOURCE: William Edwards, COO, Intrepid ISSUE: Quality Improvement Program RESPONSE: Please refer to Exhibit 2. ISSUE: Indigent Care RESPONSE: IndigenUCharity care was discussed in the original application and in the 60 day meeting response. ISSUE: Psychiatric Services RESPONSE: Intrepid plans to provide the full range of services to all patients in need including patients with a psychiatric diagnosis. ISSUE: Home Health Compare Data RESPONSE: The inclusion of home health compare data is not a CON requirement. ISSUE: Biographical Information, Key Executives RESPONSE: Please refer to Exhibit 3. ISSUE: Underestimate of Start-Up Costs RESPONSE: Start-up costs were properly identified and a detail by lioe item was provided in the 60 day meeting response. Please note that the pro forma information (including the start-up cost estimate) was prepared by Donald P. Simmons, Jr., an expert in borne health reimbursement (CV attached as Exhibit 4). 3 EXHIBIT I intrepid '" HE A l T H (" ESE R V I (I S 6600 France Avenue South Suit,SIO Edina, MN 55435 Phone 9S2' 2B5' 7300 Fox 952'920'3316 www.intrepidusa,{Om February 21, 2007 My name is William H. Edwards. I am the COO of Intrepid USA Healthcare Services (F.e. of Georgia, Inc.), the applicant for a Certificate of Need (CON) to establish a home health agency in SSDR 8. Pursuant to Rule 111-2-2-.06(4)(b)(3) and the requirements as specified in the CON application, the authorized signatory for purposes of filing the application and all subsequent documents, i.e., additional information, opposition forms, amendments and such other documentation requiring an authorized signature is given to our consultant, Newell Yarborough. For consistency with this authorization, the contact person on page I is amended to indicate that I, William H. Edwards, am the contact person on behalf of Intrepid USA Healthcare Services; and, question 12 is amended to state that Mr. Yarborough is the authorized contact other than the Applicant Contact listed in question 1. For purposes of this CON application, Mr. Yarborough is authorized by Intrepid to act as our representative; and can bind Intrepid USA Healthcare Services, with respect to the requirements of the Department of Community Health in this pending CON application for home health services. Please let me know if you require any further clarification regarding this issue. Signed by: JiL iI f .' i - / b~Y'.~" William H. Edwards, COO We find a way EXHIBIT 2 Clinical Excellence and Compliance Bill Edwards, COO As we embark on our mission to become the premier homecare company in America, clinical excellence and compliance are two core values that will be incorporated in all of our initiatives. Clinical excellence is the central element of a framework that supports the delivery of quality programs and services. This excellence is achieved in part by appraising new technology, providing guidance on the appropriate utilization of treatment interventions and procedures, and developing clinical specialty programs for the management of specific diagnoses. Educational initiatives can ensure sound principles and practices, opportunities for continuous improvement, and the delivery of premier products and services. Three initiatives in the immediate future that will assist in achieving our goals and objectives are clinical specialty programs, reference guides for the clinician, and Intrepid University. Clinical Specialty Programs With current demonstrations of performance-based payments by Medicare and other third party payers, clinical specialty programs have been developed from evidence-based practices and are implemented to anticipate patient needs, prevent chronic disease complications and avoid exacerbations and hospitalizations. The ultimate goal of this strategy is to empower the patient and caregiver to manage the disease process, thereby decreasing visits per episode without compromising quality and lessen the dependence on emergent care. Each program may include but not be limited to the following; . Disease Process Overview . Clinical Pathways/Care Plan . OASIS, Documentation, and Coding Tips . Medicare Local Medical Review Policy . Assessment Instruments, Tools, and Scales . Home Care Checklists . Expected Patient Outcomes . Glossary/Terminology . Gerontologic Considerations . Research! Advances . Drug Therapy . Patient/Caregiver Teaching Guides . Patient Diary/Journal . Useful Web sites Programs scheduled for release throughout 2006: Congestive Heart Failure, Orthopedic, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Cerebral Vascular Accident, Comprehensive Wound Care, Hypertension, Rehabilitative/Restorative Care, Myocardial Infarction, Asthma, Pneumonia, and Deep Vein Thrombosis. Clinical References Reference guides for the clinician comprise numerous 5 Y, x 9 inch laminated tools for quick reference covering a range of topics from OASIS guidelines to documentation principles. Other topics include how to write an effective 485, falls and fire prevention in the home, coordination of care, and assessment and reassessment of pain. The ringed binder affords the opportunity to augment and update these guides as necessary. Intrepid University Intrepid's commitment to provide substantive employee orientation, training, and education programs will be partially fulfilled with its partnership with Care2Leam, a division of online Healthnow. With Care2Leam (www.Care2Leam.com). we will launch continuing education courses that are relevant, informative, and interesting, written by practicing professionals - and that provide market exposure for Intrepid's products and services. These programs and offerings will be accredited and possess appropriate occupational and industry approvals. Streamlined orientation and in-service programs which include testing and training activities as well as program evaluation components will be provided. As we design, demonstrate, and investigate the best in patient care practices, recruit and retain outstanding clinicians and caregivers, and set the standards for the industry, educational initiatives will drive these key strategies. Achieving quality outcomes, assuring compliance, and exceeding client and constituent expectations through innovative practice will assist in positioning our company for success and preeminence. Together we can achieve miraculous results! EXHIBIT 3 Biography William H. Edwards, Jr., R.N., M.S. Mr. Edwards is currently Chief Operating Officer for Intrepid USA Healthcare Services, Inc. Formerly, Bill was Vice President, Chief Clinical Officer for Housecall Medical Resources, Inc., Divisional Vice President for TBN of Tennessee, Inc., President and Chief Operating Officer for Medshares, Inc., and Senior Executive Vice President and Chief Medical Services Officer for ABC Home Health Services, Inc. Mr. Edwards has over thirty years of experience in the health care industry. During this time, he has prepared and presented numerous workshops on various health care topics. Bill holds a Master of Science degree in Business Administration from Kennedy-Western University. He performed graduate study in Public Administration at The University of Georgia where he also received a Bachelor of Science degree in Education. Bill is a Registered Nurse and received his Nursing Diploma from the Medical Center of Central Georgia School of Nursing. He is currently a member of the National Association for Home Care and Hospice. Page 1 of 1 Subj: Date: From: To: CC: FW: Welcome Bill Simpson, Chief Executive Officer 2/26/2007 11 :34:51 AM Eastern Standard Time ElEdWards@jntIElpid.usa,<;Qm NDY(a)aol.com KMcKnight@lntrepidUSA.com From: Lilli Hirsh Sent: Friday, February 09, 20079:30 AM To: All IntrepidU5A Users Subject: FW: Welcome Bill Simpson, Chief Executive Officer Importance: High MESSAGE SENT ON BEHALF OF PETER HARRIS. CHAIRMAN OF THE BOARD: Please join me in welcoming Bill Simpson as the new Chief Executive Officer of the Company. Bill has more than 25 years of experience in the healthcare industry. He has a proven track record for raising quality, increasing market share and achieving profitability. His executive experience includes leading the operations of one of the largest long term acute care hospital (L TACH) companies in the country, as well as hoiding executive roles with several other L TACH companies. During his tenure with these companies, he oversaw and opened multiple hospitals, achieved JCAHO accreditation, initiated a National Medical Advisory Committee and instituted Internal Chart Audit Committees to strengthen regulatory and corporate compliance. In addition, he served as President of the largest emergency mobile medical service provider in Texas. He also served as President of EPIC Healthcare Services which managed rural acute care hospitals, and owned both surgery and diagnostic imaging centers. Bill is a graduate of Augusta College in Augusta, Georgia with a B.B.A. in Economics. He also completed executive programs at George Washington University and Harvard Business School. Bill lives in Dallas and will commute to Minneapolis until the corporate office completes its move to Dallas. He will lead Intrepid's Operating Committee, which includes Bill Edwards, Vince Bertolini, Cecelia Callis and Bill Roberts. Bill may be reached at (952) 285-7321 or bye-mail atbsimPson@intIElPidus<.com. Peter H. Harris Chairman of the Board Monday, February 26, 2007 America Online: NDY Cecelia R. Callis Vice President of Compliance Compliance Officer Ms Callis joined Intrepid in July 2003. She currently oversees the Company Regulatory and Corporate Compliance Programs and third party contracting. She had previously served as the Senior Vice President of Regulatory Affairs at Medshares, which was acquired by Intrepid. Ms Callis is a Registered Nurse and has a MPA in Health Care Administration. Ms Callis has twenty years experience in home health with a focus on State and Federal regulations. . Years in Home Health Industry: 20 . Years in Health Care: 38 total . Years with Company: 4 Page 1 of 1 Subj: (no subject) Date: 2/26/2007 11 :39:29 AM Eastem Standard Time From: ElEdWilIds@intIepidusa,cam To: NDY@aoLcaill CC: KMcKniaht@lntrepidUSAcaill Started March 13, 2006 as VP of Sales and Marketing for Intrepid, Monday, February 26,2007 America Online: NDY Vince Bertolini 1345 Lamont Circle Dacula, GA 30019 Hm. 678-546-0708, Off./Fax 678-546-0483 (678) 429-7768 cell Paul Sanderson 615-260-3205 E-Mail: vincebertolini(ci)yahoo.com OBJECTIVE To continue and advance a professional sales management career with a dynamic growth oriented healtheare corporation whereby acquired experience and knowledge in sales and sales management can be applied to aid in the future growth and success of the corporation. EMPLOYMENT ROTECH HEALTHCARE, INC. ATLANTA, GA 07/03 -1/06 DIVISION DIRECTOR OF SALES, SOUTHEAST DIVISION Rotech Healthcare is one of the nation's largest providers for respiratory therapy, & durable medical equipment. The company executed reorganization in December of 2005 where my position was eliminated. . Annual revenue responsibility, 175 milliou dollars . Direct Reports, four Region Managers of Sales, division consists of 4 Region Managers, 12 Area Managers, 160 sales representative, 11 states . P&L responsibility wi Division Director of Operations APRlA HEALTHCARE, INC. ATLANTA, GA 09/00 - 07/03 VICE PRESIDENT OF SALES, SOUTHERN REGION Apria Healthcare Group - the nation's largest provider for respiratory therapy, durable medical equipment, and infusion therapy. In addition to managing all sales efforts in the Southern Region, duties also included the negotiating of managed care contracts, DAIBCC agreements, and acquisitions. . Annual revenue responsibility, FY2000, 44 million dollars, FY2001, 49 million dollars, FY2002, 66 million dollars . Direct reports, onc Area Sales Manager, two Market Managers, two Region Account Managers, one Region Infusion Account Manager, one Administrative Assistant . P&L responsibility for the Southern Region, responsible for twenty-eight sales associates . 100.4% to plan, FY2000 . 106.7% to plan, FY200 I . II % growth, FY2002 BW MEDICAL GROUP ATLANTA, GA 2/00 - 9/00 NATIONAL SALES MANAGER National Sales Manager, BW Medical Group, [nc., - a holding company for three separate healthcare entities providing services in medical device repair, single use device reprocessing, and contract sterilization for acute care facilities. Managed all sales efforts within the United States. Also responsible for all national and corporate account activities and contract management. . Annual revenue responsibility, 13 million dollars . Direct reports, six Region Managers, three Territory Managers, one Marketing Manager . Responsible for all sales efforts within SterOut, F AMSR, and REPROMED . P&L responsibility for the entire BW Medical Group sales and management team to include all satellite repair facilities/offices . A warded the first national account contract, Novations, Inc., valued at seven million dollars STERIS CORPORATION MENTOR, OB 07/94 - 02/00 STERIS Corporation is the world's leader in the manufacturing and marketing of surgical tables, surgical lights, sterilization and decontamination systems, patient transport systems, and gas delivery systems for use in surgical suites & operating rooms as well as central sterilization departments. DIRECTOR of SALES & MARKETING, US HEALTHCARE DIV. 07/97 - 02/00 . Annual revenue responsibility, 90 million dollars, U.S. Healthcare Division, Southeast . Direct reports, five Region Sales Managers, five Sales Specialists, two Systems Project Managers, and one Clinical Specialist . Assisted in the building and implementation of the Clinical & Sales Specialist Team . P&L responsibility for the Southeastern Zone, Atlanta, GA . Sales force integration: ~ Joslyn Sterilizer Corporation, Hausted Patient Handling Systems ~ Calgon Vestal Laboratories, Surgicot, Capital & Consumables sales management team . Sales development of major !HDNs calling on CEOs, CFOs, CIOs, etc. . Responsible for quarterly reviews with major healthcare distributors . Responsible for the development of compensation plans, territory expansion and alignments . Course Instructor, C.O.S. classes for Sales Representative training . Recipient of the FY99 CEO Sales Achievement A ward . Annual revenue responsibility, 45 million dollars, Consumables Division . Jointly responsible for the establishment and implementation of the distribution program along with a distributor growth incentive program . Developed and grew the distributor business to nearly 50% of the annual revenue . Developed new pricing strategies with major GPOs and !HDNs, called on CEOs, CFO's, etc. REGION SALES MANAGER . Annual revenue responsibility, 13 million dollars . Direct reports, five Sales Representatives . Sales force integration, American Sterilizer Corporation, AMSCO . FY97 Hexawave Award . Cleveland Region, 115% to plan, FY97 08/96 - 07/97 SENIOR SALES REPRESENTATIVE TECHNICAL SALES REPRESENTATIVE . Hexawave A ward, FY96 . Paragon Award Nominee, FY96 . Setting The Standard Award, FY96, 137% to plan . Setting The Standard Award, FY95, 158% to plan 08/95 - 08/96 07/94 - 08/95 UNITED STATES SURGICAL CORP. HOUSTON, TX CERTIFIED STAPLING TECHNICIAN STRYKER ENDOSCOPY CHARLESTON, SC SALES REPRESENTATIVE SAFETY EQUIPMENT COMPANY CHARLESTON, SC SALES REPRESENTATIVE 04/93 - 04/94 04/91-04/93 07/87 - 04/91 EDUCATION The Citadel, The Military College of South Carolina Class of 1986 Bachelor of Science, Physical Therapy, Education Charleston, SC Activities: Dean's List, Gold Stars, Carrigg Scholarship, Varsity Track, 2 Year Letterman, Cardiac Rehabilitation Counselor, Special Olympics Volunteer, S.C.C.C., Corporal EXHIBIT 4 CIRRICULUM VITAE 140 I Carol Street La Habra, California 90631 Donald P. Simmons, Jr. (562) 547-3036 Qualifications Summary 18 Years experience in Medicare Home Health Agencies and Home Office Cost Reimbursement. Qualified as an expert witness in Medicare reimbursement in: Alabama, Florida, Kentucky, North Carolina, and Tennessee. Held executive level position with one of the nation's largest Medicare certified home health providers. Held supervisory position with Medicare regional intermediary. Experience Owner, Donald P. Simmons, Jr., Accountant, La Hahra, California (January 1993 to Present). Home Health Agency consulting services. Services include cost report preparation, budgeting, cost analysis and strategic planning. Reimbursement Manager, Corporate Office, ABC Home Health Services, Inc., Brunswick, GA (June 1993 to December 1993). Reported to directly to VP of Accounting. Responsible for supervision of reimbursement staft~ preparation of medicare cost reports, interim payment reports, coordination with medicare auditors during audits, medicare/medicaid appeals and information requests from all government agencies as related to medicare/medicaid matters. Director of Reimbursement, ABC Management Services, Inc. (April 1992 through June 1993). Reported to VP of Financial Services. Responsible for supervision of reimbursement staff, accounts receivable and accounts payable staff for managed services clients, proposals for management services contracts, budgeting, monthly reports, interim payment reports and cost reports. Reimbursement Specialist, ABC Home Health Services, (January 1991 to April 1992). Reported to Reimbursement Manager. Responsible for interim rate reviews, cost analysis, information requests, and special projects. Represeutative/Auditor, Aetna Life aud Casualty, Clearwater, Florida (April 1986 to December 1990). Reported to the Administrator. Responsible performing interim rate reviews, desk reviews, performing and supervising audits of medicare certified home health agencies and home ollices, intermediary appeals and special projects as directed. Education Bachelor of Arts, Accounting, University of West Florida, Pensacola, Florida 1984. Associate of Art, Business Administration, Gulf Coast Community College, Panama City, Florida 1982. GEORGIA DEPARTMENT OF COMMUNITY HEALTH Georgi Certificate of Need Additional Information MIASTEREILE \ '< 1t1 , "-"....j ~._-.-..- -h,,J DATE STAMP r::tr ENTER the Project Number and County below !U~ IE nn ~ for the project for which you are supplying ~ additional information. Use the Format YYYV-###. PROJECT NUMBER JA~I 2 6 ?oe] GA 2006 - 131 1....----- DIVISION OF HEALTH PLANNING COUNTY: Sumter S~"d Orig;,,' ,"d 1 Copy ~ {This Box for Division of Health Planning Use 0 Name of Applicant: Intrepid USA Healthcare Services General Information: 1. This Additional Information form is a required document that must be submitted by an Applicant wishing to supply additional information. Additional information is information and data submitted in response to a direct request from the Department at the 60-day meeting or information submitted consistent with the scope, physical location, costs, charges, and owners identified in the original application. 2. Please review this form before attempting to complete and submit the information requested. 3. This form must be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 4. All form fields must be completed. If a field is not applicable, so indicate. 5. Attach you additional information to this form. 6. This form and the attached additional information must be submitted to the Department no later than the 75th day of the review cycle. Applicants must submit a signed original and one (1) copy of this form and any and all attached documentation. 7. The signed original Additional Information form and the single copy must be submitted on loose leaf, one-sided 8 % by 11-inch paper only. The copy and the original should be rubber banded to separate the copy from 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. 8. Faxed copies of documents and information are not official and must be followed-up with the original documents by the mandated deadline for inclusion in a project master file. State of Georgia: Certificate of Need Additional Information Form CON 104 Revised September 2006 Page 1 SECTION A. IDENTIFYING INFORMATION 1. Please identify the Applicant. APPLICANT Applicant Legal Name: F. C. of Georgia, Inc. d/b/a (if applicable): Intrepid USA Healthcare Services (Intrepid USA) Address: 6600 Frances Avenue South, Suite 510 City: Edina State: MN I Zip: 55435 County: Hennepin Main Business Phone: 952-285-7300 2. Please identify the person to whom the Department may address questions regarding this Additional Information. CONTACT PERSON Name: Newell D. Yarborough, Jr. I Title or Position: Consultant Address: 103 Marsh Edge Lane City: Savannah I State: GA I Zip: 31419 Phone: 912-925-5896 I Fax: 912-925-0107 E-mail Address: ndy@aol.com 3. Additional Information. Attach 8-1/2 by 11-inch sheets providing the information and data in response to the direct request from the Department at a 60 day meeting or at any other time prior to the 75th day, or other information consistent with the scope, physical location, costs, charges, and owners identified in the original application. Is the attached information in response to the 60-day meeting? I:8J Yes 0 No If the information is not in response to the 60-day meeting, please explain. State of Georgia: Certificate of Need Additional Information Form CON 104 Revised September 2006 Page 2 4. Applicant Certification. By signing below, a) I hereby certify that the contained statements and all attachments hereto are true and complete to the best of my knowledge and belief and that I possess the authority to submit this form and bind the Applicant to promises made herein; b) I further understand that if issued a Certificate of Need, the Applicant is bound to any representations that have been made within this form and any and all documentation attached hereto; and c) 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 Title: Consultant Date: 1/24/07 Submit to: Division of Health Planning Department of Community Health 2 Peachtree Street, NW - 5th Floor Atlanta, GA 30303 State of Georgia: Certificate of Need Additional Information Form CON 104 Revised September 2006 Page 3 Intrepid USA Healthcare, GA Project #: 2006-131, SSDR 8 60 Day Meeting Response 1. Indigent Care Plan . Intrepid USA ("Intrepid") is committed to provide indigent and charity care in the amount of at least 3% of adjusted gross revenue. Intrepid is committed to assisting to identify the indigent and charity care needs in the community for home health care services and to assist in meeting those needs. The Intrepid policy, Indigent/Charity Care, was previously submitted and is attached for review at Exhibit 1. Additionally: . The new agency will establish a Professional Advisory Committee, as required by CMS. The membership will consist of at least one community member with specific interest in the home health needs of the poor. One purpose of this committee will be to advise Intrepid USA on initiatives to help address identified needs. . Intrepid will meet with staff of community service organizations that serve the indigent and poor to inform them of Intrepid's services. Intrepid will work with these organizations to develop methods/processes for identifying residents in need of home care but who do not have the means to pay for these services. A process will be developed for these organizations to refer these residents to Intrepid. . Intrepid marketing staff will market its services to physicians and other providers who are known to treat underserved populations who lack the funds to obtain adequate and appropriate home healthcare services. . All marketing brochures/documents will include a statement of Intrepid's commitment to providing services to indigent and charity care residents/patients. . Intrepid will provide Medical Social Workers to evaluate and document the fmancial status of the resident/patient and refer to organizations for financial counseling, as appropriate. . Intrepid will monitor its commitment by preparing quarterly analysis and review of its indigent/charity services. Monitoring will also identify potential issues to allow timely correction. . The agency Administrator's annual performance review will include criteria related to the achievement of this commitment. . The agency will incorporate this commitment statement into the new-hire orientation in an effort to ensure that all staff is aware of the commitment and share our commitment to assist in meeting the community needs. Regarding historical indigent/charity care, Intrepid serves all patients referred to us for care regardless of their ability to pay. There has never been a case where a patient was not served because of their inability to pay. Home health agencies do not control the payor class of patients referred for care. Phoebe Putney hospital (NFP which receives indigent care funding) receives the vast majority of indigent/charity home health patients. Intrepid's business comes from the "non-Phoebe" network and virtually all the indigent/charity care is within the Phoebe network. 2. Reasons Intrepid Should be Approved . Intrepid plans on serving more of the need than Amedisys. . Clinical program offerings such as Wound V AC (a machine that stimulates the wound bed and removes any fluids or drainage. This equipment is used for the "worst of the worst" wounds). 100% of Intrepid's nurses are Wound V AC certified (Please refer to the "Community Linkage" discussion in this document for more information). (See Exhibit 2 for list of other clinical specialty services offered by Intrepid.) . Sufficient existing staff that could begin serving the area immediately. Also, a Physical Therapist has already been hired for the Americus agency (Please note the comments regarding the lack of a suitable PT provider in SSDR 8 in the "Community Linkage" discussion in this document). . Intrepid has one of the lowest acute care hospitalization rates in Georgia (in the top 10% of Georgia home health agencies). . Support from the only Surgical Oncologist in Southwest Georgia, Bradley Davidson, MD (Please refer to the "Community Linkage" discussion in this document for more information). . Support from the only Cardiovascular Surgeons in Southwest Georgia (Please refer to the "Community Linkage" discussion in this document for more information). . Support from the largest surgical practice in Southwest Georgia (please refer to the "Community Linkage" discussion in this document for more information). . Support from the largest Internal Medicine practice in Southwest Georgia (Please refer to the "Community Linkage" discussion in this document for more information). Comments on Competing Applicants: United's project costs of$228,363 seem unreasonably high (it is also the identical amount they proposed for the expansion application in SSDR 4). For example, the typical start-up cost for a new agency is around $35-$75,000. Start-up costs are typically kept as low as possible since they are an amortized (five year period) expense. To become Medicare certified, a new agency has to be fully functional in terms of policies and procedures and serve 10 patients. The Administrator typically performs these initial patient visits. Visiting staff are only added after Medicare certification is achieved (three to six month period). The other costs incurred during this period are rent, utilities, office supplies, telephone and such. The total costs should be much less for an expansion. According to the SSDR 12 reviewer, United has experienced significant delays in implementing past CON projects in a timely manner. Amedisys' project costs are also unreasonably high ($125,000) especially for an expansion application. Amedisys has experienced significant delay in implementing past projects in a timely manner according to information discussed at the 60 day meetings. Furthermore, Amedisys currently serves two of the need counties, Schley and Taylor and consequently contributed to the need which suggests that they cannot meet the need in the proposed expansion counties. While Amedisys Macon reported Indigent/Charity at 3% of AGR, it appears that this level ofI/C is the exception rather than the rule as documented by the following data: 01/24/2007. Ga DCH HHA Survey(b); unedited data. Gross Gross Gross Adjusted $I&C SS Charity Indigent Ind&Char Gross %of UID DR County HHA Year Care Care Care Rev(AGR) AGR HHA047 1 Pickens Amedisys NW HH Jasper 2003 0 3,552 3,552 3,675,410 0.10 HHA047 1 Pickens Amedisys NW HH Jasper 2004 0 9,815 9,815 3,768,829 0.26 HHA047 1 Pickens Amedisys NW HH Jasper 2005 0 7,905 7,905 4,647,147 0.17 HHA014 3 Fulton Central HH AtlantalAmedisys 2003 0 114,108 114,108 10,163,934 1.12 HHA014 3 Fulton Central HH AtlantalAmedisys 2004 0 73,742 73,742 11,470,983 0.64 HHA014 3 Fulton Central HH Atlanta/Amedisys 2005 0 85,669 85,669 13,714,743 0.62 HHA031 4 Spalding Amedisys NW HH Griffin 2003 0 0 0 1,392,978 0.00 HHA031 4 Spalding Amedisys NW HH Griffin 2004 0 1,250 1,250 1,240,884 0.10 HHA031 4 Spalding Amedisys NW HH Griffin 2005 0 7,329 7,329 2,781,296 0.26 HHA020 5 Newton Amedisys HH Covington 2003 0 5,083 5,083 3,455,438 0.15 HHA020 5 Newton Amedisys HH Covington 2004 0 4,407 4,407 4,505,296 0.10 HHA020 5 Newton Amedisys HH Covington 2005 96,213 61,007 157,220 5,567,157 2.82 HHA075 6 Bibb Amedisys HH Macon 2003 0 260 260 3,007,102 0.01 HHA075 6 Bibb Amedisys HH Macon 2004 0 1,208 1,208 2,863,864 0.04 HHA075 6 Bibb Amedisys HH Macon 2005 57,593 23,957 81,550 2,711,947 3.01 HHA091 11 Lowndes Amedisys HH Valdosta 2003 0 1,153 1,153 606,092 0.19 HHA091 11 Lowndes Amedisys HH Valdosta 2004 0 125 125 982,477 0.01 HHA091 11 Lowndes Amedisys HH Valdosta 2005 13,981 41,943 55,924 1,826,993 3.06 2 3. Start-up Cost Breakdown Start-up Costs for the Intrepid SSDR 8 Application are as follows: Administrators Salary Fringe Benefits Clerical Wages Fringe Benefits Skilled Nursing Fringe Benefits Office Supplies Contract Svcs. / Consulting Communication/Telephone JanitoriaV Plant Operation Postage & Couriers Building Rent Utilities Total Start-up Costs* $16,251.00 $ 2,437.65 $10,669.00 $ 2,400.53 $ 4,729.20 $ 1,064.07 $ 2,184.00 $ 111.00 $ 5,238.00 $ 570.00 $ 588.00 $ 2,250.00 $ 939.51 $49,431.96 * Total Start-Up Costs rounded up to $50,000.00 in the application 4. Staff Productivity As noted in the Pro Forma assumptions (second item in Appendix G ofthe original application), Full time equivalents were computed as follows: All disciplines except for Medical Social Services, were based upon a 260- day work year performing 5 visits per day. Medical Social Services was based upon a 260-day work year performing 3 visits per day. Administrative staff was based upon a 2080-hour work year (page 4 of the assumptions). All disciplines except Medical Social Services translates into 1300 visit per year per FTE (260 x 5). These productivity standards are those published by the National Association for Homecare (NAHC). The area average for non-Medical Social Services staffwas stated to be 860/FTENear, an unreasonably low productivity standard which translates into only 3.3 visits per day per FTE. The following table and the text that follows was excerpted from NAHC's "Basic Statistics About Home Care", page 12. Please note that while these are average numbers, they served as a reasonable basis to compute the FTEs required for the project. Table 14. Home Health Care Visit Staff Productivity per 8-Hour Day (Actual Visits Performed) Registered Nurse Home Care Aide Physical Therapist Occupational Therapist Social Worker 4.95 5.17 5.50 5.30 3.35 Source: National Association for Home Care & Hospice, Hospital & Healthcare Compensation Service. Homecare Salary & Benefits Report 2003-2004. October 2003 "c. Productivity Since 1996, NAHC has worked with the Hospital and Healthcare Compensation Service (HCS) to conduct an annual survey of compensation in the home care and hospice industry. This agreement avoids duplication of effort in data collection by combining the efforts of both organizations. Employee productivity data is now collected in this survey. Productivity in home care is typically based on the average number of visits provided per day. Table 14 shows data from the Homecare Salary & Benefits Report 2003-2004." 3 5. Plan for Meeting the Need Initially, the entire service area will be served from the main office in Americus (Sumter County). Branch offices will be established in other counties within the service area when there is sufficient patient caseload to justify the establishment of additional offices. Americus was selected for the initial office since it is the largest city in the proposed service area and many patients come to Albany (where Intrepid is also located) for their health care and many ofthe company's existing referral sources also have offices in Americus and these referral sources would like Intrepid to have the ability to serve all their home health patients in Sumter County. The following table provides population by age cohort for the proposed service area counties. POPULATION COHORTS BY SERVICE AREA COUNTY, 2009 SS Grand Age Age Age Age Fems Year DR County Total 00-17 18-64 65-79 80+ 75+ 2006 8 Chattahoo. 20,110 5,971 13,744 318 77 88 2006 8 Clay 3,417 913 1,753 504 247 249 2006 8 Harris 28,116 6,929 16,959 3,047 1,181 1,175 2006 8 Macon 14,330 3,950 8,409 1,323 648 683 2006 8 Marion 7,270 1,975 4,375 648 272 278 2006 8 Quitman 2,388 613 1,229 380 166 156 2006 8 Randolph 7,124 2,009 3,895 794 426 435 2006 8 Schley 4,204 1,202 2,397 432 173 175 2006 8 Stewart 4,784 1,148 2,671 610 355 364 2006 8 Sumter 33,100 9,693 18,827 2,905 1,675 1,695 2006 8 Talbot 6,606 1,695 3,842 768 301 281 2006 8 Taylor 8,975 2,430 5,143 924 478 455 SOURCE: GA OPB, Revised release 4/06. Given that the 75+ female population is a reasonable indicator of the demand for home health services, the following counties proposed to be served by Intrepid represent the largest potential pool of home health patients ( in rank order): 1. Sumter (site of the proposed initial office). 2. Harris (proposed site of first branch office). 3. Macon (proposed site of second branch office). 4. Taylor (could be served from the Macon branch). 5. Randolph (proposed site ofthird branch office). 6. Stewart (could be served from Randolph). 7. Talbot (could be served from Harris). 8. Marion (possible fourth branch). 9. Clay (could be served from Randolph). 10. Schley (could be served from Macon). 11. Quitman (could be served from Randolph). 12.Chattahoochee (could be served from Marion). The following map shows the density ofthe ofthe 75+ female population by service area county (a more sensitive measure of home health demand than the 65+ population since the typical home health patient is a female age 75+). 4 Female 75+ Population By Service Area County HARRl$ (1,390) UMA (t=emale 75+ Pop. 2009) Source: Ga OPB 04106 30 miles Figure 1 As can be seen from this figure, Sumter County has the largest concentration offemales age 75+. 6. Community Linkages Information provided by the client on 1/23/07: Denise Wang, Account Executive, spoke with Bill English, Director of Case Management at Palmyra Medical Center in Albany. He voiced support of the CON application, stating that Phoebe Home Care had stopped accepting referrals in Sumter and surrounding counties because of lack of staff. He stated there is a strong need in SSDR 8 for home care providers, especially Physical Therapy and that Palmyra Medical Center would refer patients in SSDR 8 to Intrepid USA. Denise Wang, Account Executive, spoke with Dr. Price Corr, a Surgeon, and his nurse Terri who both stated they have patients in Sumter, Randolph and Clay counties and would like to be able to refer them to Intrepid USA. Denise Wang, Account Executive, spoke with Dr. Bradley Davidson, a Surgeon, and his nurse Ellen. He is the only Surgical Oncologist in southwest Georgia and he stated he would like to for Intrepid USA to be able to take care of more of his home care patients because he wants an agency he can trust and he trusts Intrepid USA. Denise Wang, Account Executive, spoke with Dr. John Bagnato, a Surgeon, and his nurse Missy. He stated that he trusts his wound care patients to us over any other agency and that he would like to use us exclusively if we are granted the CON for SSDR 8. Denise Wang, Account Executive, spoke with Dr. Thomas Bozzuto and Dr. James Freeman at the Phoebe Putney Wound Care Center said they would like to use Intrepid USA, especially in Sumter County. They said that there is not an agency in that area with Wound V.A.C expertise and they have a need for that. 5 Denise Wang, Account Executive, spoke with Dr. Craig Murray, General Surgeon, stated he has a need for an agency in Sumter and the surrounding counties with Wound V.A.C expertise. He was also complementary of Intrepid's Diabetic Program and stated it was helpful in patients with wounds complicated by diabetes. Denise Wang, Account Executive, spoke with Dr. Rex Ajayi, Urologist stated he has many patients in Randolph and Sumter counties and would like for Intrepid USA to be able to take care of his home care patients, especially those who have long term catheters and who live in those counties. Denise Wang, Account Executive, spoke with Dr. Paul Peach, Rehabilitation doctor and his office manager Ruth Spell, who stated that Intrepid USA is his preferred home care provider and he would refer all of his patients in SSDR 8 for home nursing and therapy. Denise Wang, Account Executive, met with the three physicians at Albany Orthopedics, Dr. Duncan Marsh, Dr. Scott McGee and Dr. Daniel Rhoads. They also have an office in Americus and they said they would use Intrepid USA for home therapy and nursing services for their patients in SSDR 8. Denise Wang, Account Executive, spoke with Dr. Harry Dorsey, Dr. Frank Jones, Dr. Joseph Stubbs, Dr. Charles Tyler and Dr. Paul Donnan of Albany Internal Medicine. They all voiced support of the CON application. They stated that Intrepid USA is their preferred home care provider and that they would refer all of their patients in SSDR 8 to Intrepid for home health care. Denise Wang, Account Executive, met with Dr. Michael Satchell who stated he has current patients in Randolph and Sumter counties. He stated he prefers Intrepid USA for home health care because he feels we monitor his patients' status better and do a better job of keeping him informed of their condition better than other agencies. Denise Wang, Account Executive, spoke with Dr. Wayne Holley, Dr. Anthony Hoopes and Dr. Frances Herrbold, (all Cardiovascular surgeons) voiced their support of the CON application. They are the only cardiovascular surgeons in southwest Georgia and have many patients in SSDR 8. They stated they prefer to use Intrepid because of the high quality of nursing care provided and because our nurses always follow up appropriately, stating they feel that other home care agencies in the area do not keep them informed ofthe patient's status as well as Intrepid USA. Denise Wang, Account Executive, met with the six physicians at the Albany Urology Clinic and their staff, who all voiced support of the CON application. They stated that they have many patients in SSDR 8 and would like the ability to use Intrepid USA because we keep them informed and have better follow up than their current provider in SSDR 8. They stated that Intrepid is much easier to use than any other agency in the area and they feel that their patients get better care from Intrepid. Denise Wang, Account Executive, spoke with Fran, Director of Rehabilitation Services at Palmyra Medical Center. She stated that currently their patients from SSDR 8 who need home care have to go to outpatient therapy because there is not a suitable home PT provider in SSDR 8. She stated that they would refer their patients in SSDR 8 for home PT and nursing. Becky Daniel, Account Executive, spoke with three surgeons at Albany Surgical Associates, Dr. Price Corr, Dr. Christopher Smith and Dr. John Burnette. Albany Surgical is the largest surgical practice in southwest Georgia. They voiced their support of the CON application, stating that Intrepid USA is their preferred home care agency and they want us to secure regulatory approval for SSDR 8 so we can take care of all of their home care patients. They stated that Intrepid is the only home care agency they trust to take care of their wound V.A.c. patients. Becky Daniel, Account Executive, spoke with Dr. Glenn Williams, Dr. Thomas Darden, Dr. James Mason and Dr. Mark Wolgin of Orthopedic Associates, Inc. They stated that they have an office in Sumter County and they prefer Intrepid USA to provide their home nursing and Physical Therapy. They stated they would refer all of their patients in SSDR 8 to Intrepid. Becky Daniel, Account Executive, met with the physicians of Southwest Georgia Orthopedics, Dr. Bennett Cotton, Dr. Bob Prince, Dr. David Bank and Dr. Usup Choi. They stated that they have many patients who live in SSDR 8 and they would like to use Intrepid USA for home physical therapy. They have phoned our Albany office several times with referrals for patients who live in SSDR 8. They currently refer their patients in the Albany agency's service area to Intrepid USA. 6 Becky Daniel, Account Executive, spoke with Dr. Charles Gebhardt, an Internist who specializes in Nutrition and Diabetes. He voiced support of our diabetes program and states that he has patients who live in SSDR 8 and that he would refer all of his home care patients in SSDR 8 to Intrepid. Becky Daniel, Account Executive, spoke with Dr. Maher Astwani, an Albany Neurologist. There are no Neurologist in Sumter and the surrounding counties. Dr. Astwani states he has many patients in SSDR 8 and that he currently uses Intrepid USA for home nursing, physical and occupational therapies in our current coverage area and that he would refer all of his patients in SSDR 8 to Intrepid. Becky Daniel, Account Executive, spoke with Dr. Devell Young. He said that Intrepid USA is his preferred home health care provider and he has patients who live in SSDR 8 and that he would defmitely use Intrepid for those patients. Becky Daniel, Account Executive, spoke with Dr. Stephen McLendon, Dr. Brian Keefe, Dr. Kay Kitchen and Dr. Anita Bell, Internal Medicine physicians with Albany Internal Medicine, the largest Internal Medicine practice in southwest Georgia. They stated that Intrepid USA is their preferred home care provider and they would like for Intrepid to be able to provide home care to their patients who live in SSDR 8. Becky Daniel, Account Executive, met with Dr. Harry Weiser, a Neurosurgeon in southwest Georgia, states he has many patients who live in SSDR 8. He stated he is very pleased with the home care provided by Intrepid USA in our current coverage area and he would like for Intrepid to be able to care for all of his home care patients. Becky Daniel, Account Executive, spoke with four podiatrists at Albany Podiatry. They said they have many patients in SSDR 8 and would definitely use Intrepid USA for those patients who needed home care. Becky Daniel, Account Executive, spoke with Dr. Ramana Rao and Dr. Jyotir Mehta, Pulmonologists, who said that they currently use Intrepid USA for their patients in the Albany agency's service area, that they have patients who live in SSDR 8 and that they would definitely use Intrepid USA for those patients. Becky Daniel, Account Executive, spoke with Evelyn Mazza, Judy Pearson, Patsy Gerbert, Case Managers and Discharge Planners at Palmyra Medical Center in Albany. They said they have a lot of patients who live in SSDR 8 and that they would refer them to Intrepid USA if we were able to secure a CON. (See Exhibit 3) 7. Existing Payor Mix (Intrepid USA: Combined total for: Brunswick, Kingsland, Albany, Camilla, Valdosta & Homervile) Total 2006 2006 % Private Gross Revenue 2,070.00 19,368.00 0.38% Commercial Gross Revenue 44,298.60 573,799.01 11.40% Medicare Gross Revenue 558,929.80 4,163,755.85 82.73% Medicare HMO Gross Revenue 1,820.89 43,943.66 0.87% Medicaid Gross Revenue 26,407.04 232,145.00 4.61% Total Gross Revenue by Payor 633,526.33 5,033,011.52 100.00% Private Sales Adjustments (91.65) (3,062.73) (0.07%) Commercial Sales Adjustments (22,013.67) (280,948.54) (6.78%) Medicare Sales Adjustments (29,025.73) (427,339.45) (10.31%) Medicaid Sales Adjustments (19,359.67) (176,489.84) (4.26%) Total Sales Adjustments by Payor (70,490.72) (887,890.63) (21.42%) Private Net Revenue 1,978.35 16,305.27 0.39% Commercial Net Revenue 22,284.93 292,850.47 7.06% Medicare Net Revenue 529,904.07 3,736,416.40 90.14% Medicare HMO Net Revenue 1,820.89 43,893.59 1.06% Medicaid Net Revenue 7,047.37 55,655.16 1.34% Total Net Revenue by Payor 563,035.61 4,145,120.89 100.00% 7 8. Cash Reserves As stated in the letter from Gregory Von Ark, Intrepid USA's CFO in Appendix G of the original application, "F. e. of Georgia, Inc. is a subsidiary afIntrepid US.A., Inc., which in turn is owned by private funds, managed by Patriarch Partners, LLC ("Patriarch'). Patriarch currently manages funds representing an aggregate $5 billion in assets under management. " Given that the total estimated project costs are $70,000, Intrepid USA has access to more than adequate funds to implement the project. (See Exhibit 4 - Letter from Controller). 8 EXHIBIT 1 INDIGENT/CHARITY CARE POLICY Intrepid USA Healthcare Services Policy and Procedure ;-.----.-.---------------.---.,----.-------..----- L!'..~_~i~y_..~_a.~~~_ i,lndigent I Charity Care - Georgia i ! i' I i . S' ",'i_ .2 ii" Ca.re De-I..very L~~.!!.~!': -- i L E(ff!~!b'e J?at~~ I Qctober 12, 2006 i ! I I I Policy Number: I 2.888 GA f i I i I Revision Date: I Policy Statement: To define the processes and required approvals necessary to engage in the provision of services to indigent clients. The agency will provide care to all clients regardless of the client's abilitY to pay, as allowed by agency resources. Indigent care is defined as all unpaid charges for services to clients whose family income level was equal to or less than one-hundred-fifty (150) percent of Federal Poverty Guidelines, excluding those unpaid charges classified as contractual allowances for Medicare or other free care such as courtesy allowances, policy discounts, and administrative adjustments. Guidelines I Procedures: 1. Clients who are unable to pay for services are accepted for care under certain conditions. 2. If there is no third-party source for reimbursement of services, the client (or his/her-guarantor) is responsible for payment. 3. Cases arise whereby the client or guarantor is financially unable to pay for service due to income. The ability to provide funding to those clients who do not have the means" to pay is limited to the amount designated for that purpose by the agency. 4. The Referral/Intake staff obtain and verify insurance and financial information from the client or referring party. Staff verifies insurance coverage. . 5. If a client is determined to have no third party payor source and the client is unable to pay for home health services, the Intake nurse will consult with the Administrator and/or the Director of Professional Services, and the Social Worker to determine and document the financial condition of the client. 6. Based on the documented financial information and other pertinent documentation of the client's conditions and needs, after consultation with the physician, and with the approval of the Administrator, the home care plan will be established . 7. Medical Social Workers may also evaluate and document the financial condition of the client when Medicare B Outpatient and/or private insurance payor sources do not cover the total cost of services, and outstanding balances are anticipated, and when possible, will. assist the client in identifying alternate funding sources. 8. It is anticipated that some clients will exhaust their benefits from their payment source prior to the time when home health care is no longer needed. The Medical Social Worker will help these clients to secure an alternative payment source, if available. If no alternative is available, these clients will be reclassified as indigent/charity, as appropriate. It will be the policy of the Company to continue to provide services to these clients as long as care is warranted. . . .. ..- .... ..~. .. Intrepid USA Healthcare Services Indigent' Charity Care - Georgia Page 1 of 2 Policy 2.888GA Intrepid USA Healthcare Services Policy and Procedure /~ 9. In addition to the agency criteria for admission, which adQress appropriateness of home "health care and staff safety, the following guidelines are applied when providing uncompensated care to clients: " a. The client and/or family accept the program of care in the home and agree to leam to independently manage health care needs. b. The clienUfamily provides all supplies and pharmaceuticals necessary to manage health care needs. c. The agency will not accept clients who require two (2) or more visits per day without appropriate compensation from the discharging institution. The Director of Client Care and Administrator negotiates this on a case-by-case basis. d. Referrals to the agency for uncompensated care must include a Social Work referral. e. Cases accepted outside of the above guidelines must be approved in advance by the Director of Client Care, or the agency Administrator. 10. If the agency is unable to admit the client or to continue to deliver service, every effort will be made to refer the client to an appropriate institution, state, local, or county agency for needed care. /~" Intrepid USA Healthcare Services Indigent I Charity Care - Georgia Page 2 of 2 Policy2.888GA EXHIBIT 2 INTREPID CLINICAL SPECIAL TV PROGRAMS 1M Fax: Clinical Specialty Programs 2006 Programs: . Congestive Heart Failure (CHF) . Chronic Obstructive Pulmonary Disease (COPD) . Diabetes Mellitus . Cerebral Vascular Accident (CV A)/Stroke Management . Hypertension (HTN) . Myocardial Infarction (MI) . Asthma . Pneumonia . Wound Care Program . Rehab/Restorative Care 2007 Programs: . Deep Vein Thrombosis . Amyotrophic Lateral Sclerosis . Parkinson I s Disease . Falls Risk/Prevention Program . Peripheral Vascular Disease . Palliative/Terminal/End-of-Life Care . Pre-op Orthopaedic Services Program We find a way EXHIBIT 3 LETTERS OF SUPPORT Suzanne Ryan, RNj Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 'PHOEBE WOUND CARE . &HYPERBARlC C E N T E R 803 ~ORTHJEFFERSON STREET ALBANY, GEORGIA 31.701 Dear Suzanne, I understand that Intrepid .USAhas applied to open a Medicare .certifiEi!dhome health agency in SSDR 8. In add.ition to patients in the Albany area, many of mypatierlts live in the counti.es located inSSDR 8. '.currentlyuse Intrepid USA forthe patients inyour current service area andam very pleased with thequalityof care theyreceive.J would use your new agenoy without hesitation and feel it would provide an inoreased continuifyof oare for my home oare patients. I fully support your efforts to obtain the new CON. Sincere'Y'YJt;:~9^elg'v~ ~. v . 803 NORTH JEFFERSON STREET I ALBANY, GEORGIA 31701 I PHONE.(229) 312-7600 / ALBANY GENERAL SURGERY, P.C. 910 N. ]effersonStreet, Suite B Albany, Georgia 31701 P.O. Box 70725 Albany, Georgia 31708 Phone: 229.436.1830 Fax: 229.436.1832 Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. ~. 806 14th Avenue Albany, Georgia 31701 n "n (' I~\ " .~~~~ QAMILYF MEDICAL AssOCIATES, p.c. Phone (229) 888-4093 Fax (229) 888-4098 MICHAEL SATCHELL, M.D. Suzanne Ryan, RN, Administrator . Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Ms. Ryan, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8, which includes Sumter, Randolph, Clay, Quitman, Stewart, Marion, Schley, Macon, Taylor, Chattahoochee, Talbot and Harris counties. In add!tion to patients in the Albany area, many of my patients live in these counties. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation arid feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. ~ albany orthopedic center Duncan R. Marsh, M. D. Daniel D. Rhoads, M. D. T. Scott McGee, M. D. Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. Sincerely, OOW~ Daniel D. Rhoads, M.D. Meredyth Professional Plaza 2405 Osler Court Albany, GA 31707 229-435-1458 1-800-543-6185 Reese Street Medical Park Plaza 203 Rf!€se Street Amencus, GA 31709 22~924-8123 UlJ CARL V. HANCOCK, JR., M.D., FAC.S. JAMES R. HATTAWAY, M.D., F.A.C.S. KELVIN LANE, M.D., F.A.C.S. TIMOTHY S. TRULOCK, M.D., F.A.C.S. STEPHEN C. ALLEN, M.D., FAC.S. MICHAEL D. DAUGHERTY, D.O. SCOTT M. WENDLAND, D.O. Albany Urology Clinic, P.C. DiPLOMATES AMERICAN BOARD OF UROLOGY Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 PalmyraRd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. Sincerely, ..~ 1950 PALMYRA ROAD,ALBANY, GA 31701/229-883-1503 / FAX 229-438-9534 'A ALBA:\ INTERNAL MEDICI1\ffi Suzanne Ryan, RN,Administrator Intrepid USA Home Health Care .1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, INTERNAL MEDICINE Harry N. Dorsey, MD Joseph W. 5mbbs, MD, FACP. ' Frank D. Jones, MD . (/ Anita J. Bell, MD, Fi)CP Brian T Keefe,MD J. Stephen McLendod, MD Kay C.:Kitchen, MD Charles B. Tyler, MD Paul D. Donnan, MD RHEUMATOLOGY Kelly A. Timmons; MD, PhD ! Albany IntemaLMedicine and Intrepid USA have a long history of providing quality health care to the citizens of southwest Georgia. We are in full support of your efforts to open a new Medicare certified home health agency in SSDR 8, which includes Sumter County. We would use your new agency without hesitation and feel it would provide .an increased continuity of care for our home care patients. Sincerely, Jose htffif:if!! o AIMMEDICAL ASSOCIATES, PC, DBA ALBANY INTERNAL MEDICINE ~402 OSLER COURT V. ALBANY, GEORGIA31707't( 229.438.3300 YFAX229.438;3384 . ^T~,/l,,' r\..UV I. r/ INTERNAL MEDICINE HarryN.Dorsey, MD )oseph W. Stubbs, MD, FACP .' Frank D. Jones,MD (I Anita J. Bell, MD, FACP Brian T. Keefe,MD J. Stephen McLendon, MD Kay C" Kitchen,MD Charles B. Tyler, MD Paul D. Donnan, MD (I , ALBA:;~,'~,{ INTERNALMEDICll\ffi' RHEUMATOLOGY Kelly A. Timmons; MD, PhD Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, Albany Internal Medicine and Intrepid USA have a long history of providing quality health care to the citizens of southwest Georgia. We are in full support of your efforts to open a new Medicare certified home health agency in SSDR 8, which includes Sumter County. We would use your new agency without hesitation and feel it would provide an increased continuity of care for our home care patients. Sincerely, AIM MEDICAL ASSOCIATES, PC DBA ALBANY INtERNAL MEDICINE 2402 QSLER COURT 'wfAL BANY' . G.' T' " EORGIA31707)' 229-438-3300,,/ FAX229.43S-3384 INTERNAL MEDICINE , Harry N. Dorsey, MD Joseph W. Stubbs, MD, FACP Frank D. Jones, MD Anita J. Bell, MD, FACP Brian T. Keefe, MD J. Stephen McLendon, MD Kay C. Kitchen, MD Charles B. Tyler, MD Paul D. Donnan, MD AIM ALBANY INTERNAL MEDICINE Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 RHEUMATOLOGY Kelly A. Timmons, MD, PhD Dear Suzanne, Albany Internal Medicine and Intrepid USA have a long history of providing quality health care to the citizens of southwest Georgia. We are in full support of your efforts to open a new Medicare certified home health agency in SSDR 8, which includes Sumter County. We would use your new agency without hesitation and feel it would provide an increased continuity of care for our home care patients. Sincerely, . I)jku~ J. Stephen McLendon, MD AIM MEDICAL ASSOCIATES, PC, DBA ALBANY INTERNAL MEDICINE 2402 OSLER COURT Y ALBANY, GEORGIA 31707 Y 229-438-3300 Y FAX 229-438-3384 ALBANY SURGICAL, P.C. O. GREY RAWLS, JR., M.D., F.A.C.S. (RETIRED) CHRISTOPHER C. SMITH, M.D., F.A.C.S. J. PRICE CORR, JR., M.D., F.A.C.S. 401 FOURTH AVENUE P.O. BOX 1686 ALBANY, GEORGIA 31702-1686 TELEPHONE 229,434-4200 1-800-537-6107 JOSEPH J. BURNETTE, M.n A. CULLEN RICHARDSON, III, M.D., FA.C.S. Y. JOHN BAGNATO, M.D., F.A.C.S. B. SCOTT DAVIDSON, M.D., FA.C.S., F.S.S.O. SPECIALISTS IN GENERAL SURGERY / SURGICAL ONCOLOGY Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. .,. " ,50 U T H WE 5 T G ElG I A '0. RT EDIC 5 P T 5 M E I N ,E SOUTHWEST GEORGIA ORTHOPEDIC & SPORTS MEDICINE www.swgortho.com Bennett D. Cotten Jr., M.D. A.A.O.S., F.A.CS. Bobby D. Prince, M.D. A.A.O.s. A.M. Freeman Jr., M.D. A.A.O.S., F.A.Cli., li1.CS. Usup Choi, M.D. FACS., FA.A.O.s. David M.Banks.M.D. . General Orthopedics . Trauma/Fractures . Arthritis/Osteoporosis . Joint Replacement . Hand Surgery . Foot & Ankle Surgery . Sports Medicine . Industrial Medicine . Arthroscopy . Pediatric Olthopedics SOUTHWEST GEORGIA REGIONAL SPINE CENTER www.swgspine.com Edward W. Hellman, MD.. j<-'ellowship Trained Spille Sllrge01J . Pediatric tl1ru Adult Scoliosis/Spinal Deformity . Spinal Trauma/Spinal Cord Injury . Spinal Stenosis & Arthritic Cond. of the Spine . Tumors Involving Spinal Column . Degen. & Herniated Disc Disease of the Cervical, thm Lumbar Spine . Endoscopic Laser Disc Surgery October 24,2006 Suzanne Ryan, Administrator, RN IntrepidUSA 1901 Palmyra Rd Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has appli~d to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive, I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. Sincerely, Bennet D. Cotton, M,D. Southwest GA Orthopedic & Sports Medicine Center \ 2709 Meredyth Drive Suite 450 - Post Office Box 70969 - Albany, Georgia 31708 Telephone (229) 889-0018 - 1-800-239-6828 - Facsimile (229) 889-8832 n Aging Area Agency on Aging "Your Gateway to Community Services" December 18, 2006 Denise Wang Intrepid Home Health Service 1901 Palmyra Road Albany, GA 31701 Dear Denise: It was a pleasure meeting with you recently and discussing the many services that you and your agency have provided to the elderly through our senior centers. We are always appreciative of volunteers who assist with our wellness program. Jami Harper, our Wellness Coordinator, tells me that you have assisted with the University of Georgia study in Baker, Calhoun, Lee and Worth Counties. I understand that you have also provided information on foot care, blood pressure, diabetes and COPD. Thank you for all that you have done to improve the quality of life for seniors. I understand that you are interested in expanding the services of your home health agency into the Columbus area. I'm sure that they would benefit from this service. I wish you the best in this new venture. ~~~~.~ Kay H. Hind Executive Director 1105 Palmyra Road Albany, Georgia 31701 (229)432-1124 FAX (229)483-0995 /J Ii INTERNAL MEDICINE Harry N. Dorsey, MD Joseph W. Stubbs, MD, FACP Frank D. Jones, MD Anita J. Bell, MD~ FACP Brian T. Keefe, MD J. Stephen Mclendon MD Kay C. Kitchen, MD ' Charles B. Tyler, MD Paul D. Donnan, MD ti ~;~ ALBA"\ INTERNAL MEDICll'ffi Suzanne Ryan,' RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 RHEUM.A. TO LOGY Kelly A. Timmons; MD, PhD Dear Suzanne, Albany Internal Medicine and Intrepid USA have a long history of providing quality health care to the citizens of southwest Georgia. We are in full support of your efforts to open a new Medicare certified home health agency in SSDR 8, which includes Sumter County. ./ We would use your new agency without hesitation and feel it would provide an increased continuity of care for ourhome care patients. Sincerely, Frank D. Jones, MD :'402. OS~n:. ~EDICAL ASSOCIATES, PC, DBA ALBANY INTERNAL MEDICINE - OURT y. ALBANY, GEORGIA 31707 '( 229-438.3300Y FAX 229-438-3384 INTERNAL MEDICINE ..Hany N. Dorsey, MD Joseph W. Stubbs, MD,FACP ..' Frar;<k D. Jones, MD AnitaJ. Bell, MD, FACP Bria~ T. Keefe, MD J. Stephen Mclendon MD Kay C. Kitchen, MD ' Charles B. Tyler, MD Paul D. Donnan, MD ALBA:C'\, INTERNAL MEDICll'ffi Suzanne Ryan,' RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 RHEUMATOLOGY Kelly A. Timmons; MD, PhD Dear Suzanne, Albany Internal Medicine and Intrepid USA have a long history of providing quality health care to the citizens of southwest Georgia. We are in full support of your efforts to open a new Medicare certified home health agency in SSDR 8, which includes Sumter County. We would use your new agency without hesitation and feel it would provide an increased continuity of care for our home care patients. Sincerely, ;)/).0 Harry N. Dorsey, ~ "40? os~n:: ~~iCAL ASSOCIATES, PC, DBA ALBANY INTERNAL MEDICIN~ - - T y. ALBANY, GEORGIA 31707 y. 229-438-3300 Y FAX 229-438-3384 .' , d INTERNAL MEDICINE Harry N. Dorsey, MD Joseph W. Stubbs, MD, FACI",' Frank D. Jones, MD Ii d AnitaJ. Bell, MD, FACP f f Brian T. Keefe, MD J. Stephen McLendon, MD Kay C. Kitchen, MD Charles B. Tyler, MD Paul D. Donnan, MD .~ r/ ALBAj'\"{ INTERNAL MEDICll\ffi Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 RHEUM.A TO LOGY Kelly A. Timmons; MD, PhD Dear Suzanne, Albany Internal Medicine and Intrepid USA have a long history of providing quality health care to the citizens of southwest Georgia. Weare in full support of your efforts to open a new Medicare certified home health agency in SSDR 8, which includes Sumter County. We would use your new agency without hesitation and feel it would provide an increased continuity of care for our home care patients. Paul D. Donnan, MD AIM MEDICAL ASSOCIATES P , ' 2402 OSLER COURT ' . '.' C, DBA ALBANY INTERNALlv:(EDICINE y- ALBANY, GEORGIA 31707 Y 229-438-3300 YFAX 229-438-3384 O. GREY RAWLS/)'R., M.D., FA.C.S. (RETIRED) CHRISTOPHER C.,S!\UTH, M.D., FA.C.S. J. PRICE CORR, JR., M.D., RA.C.S. ALBANY SURGICAL, P.C. 401 FOURTH AVENUE' P.O. BOX 1686 ALBANY, GEORGIA 31702-168(j" TELEPHONE 229-434-4200 1-800-537-6107 , JOSEPH J;fBURNETTI1M.D. A. CULLEN RICHARDSON, 1II, M.D., F.A.C.S. V. JOHN BAGNATO, M.D., F.A.C.S. B. SCOTI DAVIDSON, M.D., F.A.C.s~ F.S.s.O. SPr:CIAL.lSTS IN GENERAL SURGERY I SURGICAL ONCOLOGY Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, Albany Surgical Associates is the largest surgical practice in southwest Georgia, and we serve many patients from throughout the region. I currently use Intrepid USA for home care service for patients in your present service area and particularly appreciate your staff's expertise in the care of \:yound VrlC r~tiPJJts. I would definitely refer patients to you in Sumter and surrounding counties (SSDR 8), should you open a Medicare certified agency . there. rt your efforts to obtain the new CON. ALBANY SURGICAL, P.C. O. GREY RAWLS, JR., 1\i.D~ RA.C.S. (RETIRED) CHRISTOPHER C. SMIrH, M.D., F.A.C.S. J. PRICE CORR, JR., M.D., F~A.C.S. 401 FOURTH AVENUE P.O. BOX 1686 ALBANY, GEORGIA 31702-1686 (I II TELEPHONE 229-434-4200 1-800-537-6107 JOSEPH J. BURNETTE, M.D. A, CULLEN RICHARDSON, III, M.D., F.A.C.S. V. JOHN BAGNATO, M.D., F.A.C.s. B. SCOTT DAVIDSON, M.D., F.A.C.S, RS.S.O. SPECIAI.ISTS IN GENERAL SURGERY I SURGICAL ONCOLOGY Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, Albany Surgical Associates is the largest surgical practice in southwest Georgia, and we serve many patients from throughout the region. I currently use Intrepid USA for home care service for patients in your present service area and particularly appreciate your staff's expertise in the care of Wound Vac patients. I would definitely refer patients to you in Sumter and surrounding counties (SSDR 8), should you open a Medicare certified agency there. . r efforts to obtain the new CON. "L -10 Christopher C. Smith, M.D. O. GREY RAWLS, JR., M.D., FA.C.SARl'f;fIRED) CHRISTOPHER C. SMITH, M.D., F.A.c.S. J. PRICE CORR, JR., M.D., F.A.C.S. ' ALBANY SURGICAL, P.C. 401 FOURTH AVENUE P.O. BOX 168p; ALBANY, GEORGIA r'31702c 1686 TELEPHONE 229-434-4200 1-800.537-6107 SPECIALISTS IN GENERAl. SURGERY I SURGICAl. ONCOI.OGY Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, JOSEPHJ.BURNETTE,M.D. A. CULLEN RICHARDSON, III, M.D., F.A.C.S. V. JOHN BAGNATO, M.D., fA.C.s. B. SCOTT DAVIDSON, r"f.D., FA.C.S., F.S.S.O. (/ Albany Surgical Associates is the largest surgical practice in southwest Georgia, and we serve many patients from throughout the region. I currently use Intrepid USA for home care service for patients in your present service area and particularly appreciate your staff's expertise in the care of Wound Vac patients. I would definitely refer patients to you in Sumter and surrounding counties (SSDR 8), should you open .a Medicare certified agency there. I fully support your efforts to obtain the new CON. Sincerely, ~ B. 'Scott Davidson, M.D. d : O. GREY RAWLS, JR, M.D., F.A.C.S. (RETIRED)n CHRISTOPHER C. SMlTH,'M.D., FA.C.S. J. PRICE CORR, JR., M.D., EA.C.s. ALBANY SURGICAL, P.C. ~Ol FOURTH AVENUE P.O. BOX 1686 ,ALBANY, GEORGIA 31702-1686 , TELEPHONE 229-434-4200 1-800-537-6107 ;- JOSEPH J. BURNETTE, lI;l;D. A.qJLLEN RICHAROSON, III, M.D., F.A.C.S. v; JOHN BAGNATO, M.D.,'F.A.C.s. B. SCOTT DAVIDSON, M.D., FA.C.S~ F.s.s.O. SPECIALlS.TS IN GENERAl. SURGERY I SURGICAl. ONCOI.OGY Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, Albany Surgical Associates is the largest surgical practice in southwest Georgia, and we serve many patients from throughout the region. I currently use Intrepid USA for home care service for patients in your present service area and particularly appreciate your staff's expertise in the care of Wound Vac patients. I would definitely refer patients. toyou in Sumter and surrounding counties (SSDR 8), should you open a Medicare certified agency there. I fully support your efforts to obtain the new CON. Sincerely, ~9ifdteatC@~ ~ ~~!31tI5JF 701 14tH AveNue A/AI'9f GetJ[1ill 31701 PHtJNe: 229-446-9477 / J!!: 229-446-9422 -"""""-,~_._"'''""'""-,."'""''"""...""-"-"" ,-".",,'""'-- Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Ms. Ryan, I currently use Intrepid USA for home health care for my neurology practice. I understand you have applied to open a Medicare certified home health agency in SSDR 8, which includes Sumter and neighboring counties. I fully support your efforts to obtain the new CON and would use your new agency for my patients in those areas. Sincerely, lZ_l?-66 8 albany orthopedic center Duncan R. Marsh, M. D. Daniel D. Rhoads, M. D. T. Scott McGee, M. D. Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. T. Meredyth Professional Plaza 2405 Osler Court Albany, GA 31707 229-435-1458 -1-800-543-6185 Reese Street Medical Park Plaza 203 Reese Street Americus, GA 31709 229-924-8123 ~ albany orthopedic center Duncan R. Marsh, M. D. Daniel D. Rhoads, M. D. T. Scott McGee, M. D. Suzanne Ryan, RN, Administrator Intrepid USA Home Health Care 1901 Palmyra Rd. Albany, GA 31701 Dear Suzanne, I understand that Intrepid USA has applied to open a Medicare certified home health agency in SSDR 8. In addition to patients in the Albany area, many of my patients live in the counties located in SSDR 8. I currently use Intrepid USA for the patients in your current service area and am very pleased with the quality of care they receive. I would use your new agency without hesitation and feel it would provide an increased continuity of care for my home care patients. I fully support your efforts to obtain the new CON. Sincerely, ~ '/IJ~ 111) . Duncan R. Marsh, M.D. Meredyth Professional Plaza 2405 Osler Court Albany, GA 31707 229-435-1458 1-800-543-6185 Reese Street Medical Park Plaza 203 Reese Street Amencus, GA 31709 229-924-8123 .~ AI~ INTERNAL MEDICINE Harry N. Dorsey, MD Joseph W Stubbs, MD, F/>,cP 1.lfr''o J.,';/kLj ~o_,,_w....,..,_~,~~_.".._.~~.,~. _" _~__'~'" ALBANY INTERNAL MEDICINE Brian 1. Keefe, MD J. Stephen Mclendon, MD Kay C. Kitchen, MD Charles B. Tyler, MD Paul D. Donnan, MD November 2,2006 RHEUMATOLOGY Kelly A. Timmons, MD, PhD Dr. Alan Brown Medical Director Cogent Healthcare 425 W. Third Avenue, Suite 500 Albany, Georgia 31701 Dear Dr. Brown: The physicians of Albany Internal Medicine wish to have Intrepid Healthcare provide home health care to our patients upon discharge from Phoebe Putney Memorial Hospital unless the patient or the patient's family wishes to have a different provider. Thank you for your assistance. Respectfull y, . ~:DO~::{ lThTDlbb AIM MEDICAL ASSOCIATES, PC, DBA ALBA:r--ry INTERNAL MEDICINE 2402 OSLER COURT "f ALBANY, GEORGI}.. 31707 "f 229-438-3300 "f FAX 229-438-3384 . ~ INTERNAL MEDICINE HarryN. Dorsey, MD Joseph W. Stubbs, MD, FACP Frank D. Jones, MD Anita J. Bell, MD, FACP Brian T. Keefe, MD J. Stephen Mclendon, MD Kay C. Kitchen, MD Charles B. Tyler, MD Paul D. Donnan, MD ALBANY INTERNAL MEDICINE November 2, 2006 RHEUMATOLOGY Kelly A Timmons, MD, PhD Dr. Alan Brown Medical Director Cogent Healthcare 425 W. Third Avenue, Suite 500 Albany, Georgia 31701 Dear Dr. Brown: The physicians of Albany Internal Medicine wish to have Intrepid Healthcare provide home health care to our patients upon discharge from Phoebe Putney Memorial Hospital unless the patient or the patient's family wishes to have a different provider. Thank you for your assistance. Respectfully, . 6!~DO~::( HND/bb AIM MEDICAL ASSOCIATES, PC, DBA ALBANY INTERNAL MEDICINE 2402 OSLER COURT Y ALBANY, GEORGIA 31707 Y 229-438-3300 Y FAX 229-438-3384 EXHIBIT 4 Proof of Financing Commitment intrepid ,. HEAlTHeARE SERVICES 6600 Franle Avenue Saulh Suile 510 Edina, MN 55435 Phone 952 - 28S - 7300 Fox 952-920-3316 www.inlrepidusa.lam January 26, 2007 To Whom It May Concern: Intrepid U.S.A., Inc. has a revolving credit facility provided by Patriarch Partners, LLC managed funds Zohar cno 2003-1, Limited and Zohar II 2005-1 Limited in the total committed amount of $ 15,000,000.00. As of to day's date, there is $5,714,066 available for use by the Company. This line of credit may be used by Intrepid U.S.A, Inc. and, or FC of Georgia, Inc. to fund the completion of the CON process in which they are currently engaged in Georgia. If you should have any questions regarding this, please do not hesitate to contact us. Thank you, &e~ Controller We find a way ~ GEORGIA DEPARTMENT 0' ,.4))1 COMMUNITY HEALTH Rhonda M. Medows, MD, Commissioner Sonny Perdue. Governor February 14, 2007 Newell D. Yarborough, Jr. Yarborough Consulting, Inc. 103 Marsh Edge Lane Savannah, Georgia 31419 RE: Project Number: GA. 2006-131 Establish New Home Health Agency in SSDR 8 Dear Mr. Yarborough: 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Enclosed please find copies of the letters of opposition to the above referenced project received by the Division of Health Planning on behalf of United Home Care of South West Georgia, InC. Please provide a response. If you have any questions regarding this matter, please contact me at (404) 463-1101. Sincerely, '~~f Karesha ~~rkeley~SHSA Health Systems Analyst Enclosures (1) Equal Opportunity Employer MA$l~R f't~ ~-..-7 '.. <""" GaO'G" D'''''TW,"T 0' .::.~;l1 COMMUNITY HI!.ALTH Georgia Certificate of Need Opposition to Project under Review t,.., , ( , i \_- ~ - --,~, <7'ENTER the Project Number and County below DATE STAMP I@ p. 0' Ie U \\/7 it; rni for the project that you are opposing. L, '.," c; , U b )" r------ 'I Use the Format VVVV-###. I Ii ' II PROJECT NUMBER I U\ FEB -~ 2007 jl0 GA I DIV"o,,,,v W WA' -'" DJ ,-, 2006 - 131 . J0!U!._ :_:.:-=,~Li r1 : Lflt},I!NG COUNTY: Sumter Signed Original and 3 Copies ~ (This Box for Division of H/Hlllh Planning Use Applicant Name: F. C. of Georgia, Inc. d/b/a Intrepid USA HealthCare Services (Intrepid USA) Opposing Party Name: United Home Care of South West Georgia Inc. General Information: 1. This Opposition form is a required document that must be submitted by a party wishing to oppose a project currently under consideration by the Department. Anyone may oppose a project, but only certain parties have standing to appeal a project that has been opposed. 2. Please review this form before attempting to complete and submit the information requested. 3. This form must be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 4. All form fields must be completed. If a field is not applicable, so indicate. 5. Attach your detailed opposition to this form. 6. This form and any and all attached sheets detailing reasons for opposition to the project under consideration must be submitted to the Department by the appropriate opposition deadline. . Opposition addressing information contained in the application as originall~ submitted by the Applicant must be submitted to the Department no later than the 60 day of the application review cycle; . Opposition addressing information contained in additional information submitted by the applicant prior to the 75'h day of the review cycle must be submitted to the Department no later than the 83'd day of the review cycle; State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 1 · Opposition addressing information contained in an amendment to the project must be submitted to the Department no later than the 85th day, except when the review cycle of the project is extended to 120 days, such opposition must be submitted to the Department no later than the 115111 day of the review cycle; . Notwithstanding the timeframes above, opposition to batched applications for home health and nursing facilities, regardless of whether such opposition is to Information contained in the original application, an amendment, or additional information, must be submitted to the Department by the 85th day of the review cycle; and · Notwithstanding the timeframes above, opposition to expedited applications, regardless of whether such opposition is to information contained in the original application, an amendment, or additional information, must be submitted to the Department by the 35th day of the review cycle. 7. Any opposition that is not submitted in a timely fashion as described in the previous paragraph will be returned and will not become part of the master file. 8. You must submit a signed original and three copies of this form and any and all attached documentation. 9. The signed original Opposition form and the three copies must be submitted on loose leaf, one-sided 8 'h by 11-inch paper only. Each copy and the original should be rubber banded to separate each copy and the original. · The signed original must not be hole punched nor stapled or otherwise bound. · The three copies must be three-hole-punched but must not be stapled or otherwise bound. 10. Faxed copies of documents and information are not official and must be followed-up with the original documents by the mandated deadline for inclusion in a project master file. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 2 OPPOSITION 1. Identify the opposing party. OPPOSING PARTY Legal Name: United Home Care of South West Georgia Inc. d/b/a (if applicable): Address: 3945 Lawrenceville Highway City: Lilburn I State: GA I Zip: 30047 2. Identify the authorized representative submitting this opposition. AUTHORIZED REPRESENTATIVE Name: I Title or Position: Address: City: I State: I Zip: Phone: I Fax: E-mail Address: 3. Does the opposing party have legal standing to appeal the appllcallon should It be approved? t8J Yes 0 No If YES") Complete the following table indicating the Opposing Party's purported standing. If NO") Continue to the next Question. You may still submit this opposition. LEGAL STANDING .. ..... . Is the Opposing Party a competing applicant? t8J Yes 0 No Is the Opposing Party a county or municipal govemment within whose DYes t8J No boundaries the project will be located? Is the Opposing Party a competing health care facility? DYes t8J No Is the Opposing Party notifying the Department of its opposition during the t8J Yes 0 No required time periods? Will the Opposing Party be aggrieved if the Department were to approve the t8J Yes 0 No application? State of Georgia: Certificate of Need Oppos"lon Form CON 105 Revised May 2006 Page 3 4. Identify the Applicant for the project that you are opposing. APPLICANT INFORMATION Applicant Legal Name: F. C of Georgia, Inc. dlbla (if applicable): Intrepid USA Healthcare Services (Intrepid USA) Address: 6600 Frances Avenue South, Suite 510 City: Edine State: MN Zip: 55435 County: Hennepin Project Number: 2006-131 Title of Applicant's Project Development of a New Home Health Agency in SSDR 8 5. Indicate the location of the Information being opposed. Check onlv one of the following: IZIlnformation contained in the original submission of the Applicant (Verify that you are submitting your opposition by the 6CJ" day of the review cycle) o Information contained in additional Information submitted by the Applicant (Verify that you are submitting your opposition by the 83" day of the review cycle) o Information contained in an amendment (Verify that you are submitting your opposition by the 85" day of the review cycle) o Information submitted in the original submission, additional information, or an amendment to a batched home health or nursing facility application. (Verify that you are submitting your opposition by the 85" day of the review cycle) o Information submitted in the original submission, additional information, or an amendment to an expedited application. (Verify that you are submitting your opposition by the 35" day of the review cycle) 6. Attach 8-112 by 11-inch sheets of paper providing the specific reasons for the opposition to the Applicant's project. Please see the attached. 7. Does the Opposing Party have any lobbyist employed, retained. or affiliated with the Opposing Party directly or through its authorized representative? IZI YES II YES -+ II NO -+ ONO Please complete the information in the table on the next page for each lobbyist employed, retained, or affiliated with the Opposing Party. 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. Continue to the next question. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 4 LOBBYIST DISCLOSURE STATEMENT Reg istered Name of LObbyist Affiliation with. with State Opposing Party Eth ies Commission? . Joe Tan ner D Employed IZI Yes IZI Other Affiliation DNo Bill Roper D Employed IZI Yes IZI Other Affiliation DNo . D Employed DYes D Other Affiliation DNo . D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliation DNo D Employed DYes D Other Affiliatio(l DNo 8. Opposing Party Certification. By signing below, I hereby certify that the contained statements and all attachments hereto are true and complete to the best of my knowledge and belief and that I possess the authority to submit this form and bind the Opposing Party to promises made herein, APPLICANT CERTIFICATION /~ LY): Name: Neil L Pruitt, Jr. Title: Chaimnan & CEO Date: ).- 5 -07 Submit to: Division of Health Planning Department of Community Health 2 Peachtree Street, NW - 5'h Floor Atlanta, GA 30303 Stale of Georgia: Certificate of Need Opposition Fonn CON 105 Revised May 2006 Page 5. United Home Care of South West Georgia Inc. F.C. of Georgia, Inc. d1b/a1 Intrepid USA HealthCare Services (Intrepid USA) Project # 2006-131 United Home Care of South West Georgia, Inc. (UHC of South West Georgia) is a competing applicant through its CON application Project #2006-132. UHC of South West Georgia opposes the application filed by F.C. of Georgia, Inc. d/b/a! Intrepid USA HealthCare Services (Intrepid). Furthermore, UHC of South West Georgia asserts that it is the better applicant to meet the identified need for SSDR 8 for the following reasons: Rule 111-2-2-.06(2) Submittal of Applications Intrepid's application should not have been accepted as complete for review. Rule 111-2-2-.06(2) requires that the application be signed by a "legal representative of the applicant". Intrepid's application was signed by Newell D. Yarborough who is listed in Question 11, page 5 of the application. As the consultant, Mr. Yarborough is not a legal representati ve of the applicant. Furthermore, Mr. Yarborough was not identified in Question 12, page 5 as a legally authorized representative of the applicant. Finally, Mr. Yarborough in his capacity as a consultant is not able to: · bind the applicant to the promises made herein (part a); · certify that the applicant will submit progress reports (part b); · bind the applicant to representation made in the application (part d); and · certify that the applicant will accept condition or conditions on the award of the Certificate of Need (part e). Because Intrepid's application was not signed by a legal representative of the applicant, the application should have resulted in non-acceptance and been returned to the applicant as further stated in Rule 111- 2-2-.06(2). As such, the application was not complete for review and should not be considered as part of the joined applications to meet the unmet need in SSDR 8 published on September 14, 2006. Rule 111-2-2-.09(1)( a); Consistency with the State Health Plan Intrepid fails to meet this general review consideration because it does not adequately address certain other general and service specific rules. Only UHC of South West Georgia proposes to incorporate the proposed agency into an integrated continuum of long term care services which will enhance access and transparency, and promote the deliver of care and services at the most appropriate and cost-effective level of care. UHC of South West Georgia and its parent and affiliates bring vast resources and a vision for how home health services should be provided as part of the larger health system focused on continuously improving quality of care, cost effectiveness of services provided at the appropriate level, and enhancing accessibility of services. This vision, as outlined in this application, is consistent with the goals of the State Health Plan, Governor Perdue's recently stated initiatives related to transparency and choice, and recent CMS initiatives. Only UHC of South West Georgia has fully integrated the Governor's initiatives into its plans. Indeed, it has committed to expand its commitments to access and transparency in cost and quality to its existing agencies as well as the proposed agency. For this reason, UHC of South West Georgia's project better meets the criteria than the other joined applicants. Slate of Georgia: Certificate of Need Opposition Fa"" CON 105 Revised May 2006 Page 6 Rule 111-2-2-.09(1)(b): Rule 111-2-2-.32(3)(b): Need for the Proposed Project Needfor a New or Expanded Home Health Agency UHC of South West Georgia better meets the need identified in SSDR 8 and should be approved. By contrast, Intrepid fails to document and describe in detail its various proposed service offerings, specific disease management tools, or specific corporate programs and services that it will bring to the counties it proposes to serve. Intrepid will not offer home health services in SSDR 8 as part of an integrated continuum of long term care services such as UHC of South West Georgia proposes. Most importantly, Intrepid fails to provide any documentation of efforts made to date or plans to develop community linkages within SSDR 8. Only a handful of letters of support were provided. UHC of South West Georgia, by contrast, has significant documentation of efforts made to develop new relationships and extensive community support within SSDR 8 for its project. For this reason, UHC of South West Georgia better meets the identified unmet need in SSDR 8. Rule 111-2-2-.09(1)( d): Financial Feasibility Intrepid proposes to develop a headquarter office as a new home health agency. However, there are insufficient funds presented in the project costs to develop a new office. Such items as office furnishing and equipment, minor medical equipment, voice and data communications, wiring, and computer technology have not been included in its project costs. As a result, start-up and capital costs cannot be verified and assurances of adequate funding cannot be reliably made. Only UHC of South West Georgia fully discloses all costs associated with the development of a branch office to consider all office furnishings, office and medical equipment, wiring, telecommunication and computer systems. UHC of South West Georgia fully discloses the costs of its technology initiatives, including the hardware, software, and training costs associated with an electronic Point of Service (POS) program. Rule 111-2-2-.09(1)( g): Rule 111-2-2-.32(1): Financial Accessibility Financial Accessibility Intrepid does not project any self pay charges for the agency in the second year of operation, yet Intrepid proposes to write off $61,944 in indigent/charity care. Intrepid has not indicated how it will meet its commitment to indigent/charity care operationally and has not provided for any non-clinical or clinical staff to assist in these efforts. UHC of South West Georgia has provided a detailed plan which includes internet posting of its policies, a specific procedure by which the indigent may apply for assistance, specified the staff that will be responsible for processing requests for assistance, and detailed who is eligible. In addition, UHC of South West Georgia has notified in writing many of the community agencies who advocate for the indigent of its intent to make services available to the indigent. The following are examples of steps being taken corporately within the United Home Care family of home health agencies: State of Georgia: Certificate of Need Opposition Form CON 105 Revised Mey 2006 Page 7 o The company web site, www.uhs-pruitt.com. has been updated to include an entire page on the availability of indigent care. Instructions regarding application and contact information are included. A "Screen Print" of the new web page, http://www.uhs- pruitt.com/Default.aspx?tabid=88, was provided in Attachment F to UHC of South West Georgia's Additional Information submission. This web site lists all United Home Care agencies and will include the proposed agency should it receive the Departments' award. o UHC has also developed an informational brochure which will be distributed to hospitals, physicians, DFCS offices, Public Health offices, and other social service agencies providing assistance to those with limited means. The brochures will be available in all United Home Care home health offices as well as all UHS-Pruitt affiliated companies. Should the applicant be awarded a Certificate of Need, brochures will be mailed to all referral sources in the region. United Home Care Community Liaison staff will personally distribute this information to all of the region's hospitals who are the most likely to have inquiries regarding charitable home care services. o UHC has expanded the role of its medical social work staff to include financial counseling to any patient or referred individual who reports needing financial assistance. An orientation program for employed staff and contract staff is being developed and is anticipated to be deployed during the first quarter of calendar year 2007. o UHC is in the process of updating its orientation and continuing education program. The new components of the program clearly describe the companies commitment to providing indigent and charitable care and make clear to all employees how to refer inquiries to social work services for financial assistance and counseling. By contrast, Intrepid provides little evidence of its ability or intent to operationalize programs that will ensure that home health services are provided within SSDR 8 to patients without ability to pay for services including indigent and charity care patients. Rule 111-2-2-.09(e): Rule 111-2-2-.32(m): Effects on Payors Comparable Charges Intrepid's application is inferior with regard to the effect on payors and comparable charges. Intrepid's projected charges per visit by discipline are higher than those proposed by UHC of South West Georgia. UHC of South West Georgia's projected charges are reasonable and within the range of existing charges for SSDR 8. Consistent with Governor Perdue's initiatives announced last fall, UHC of South West Georgia will ensure pricing transparency by providing pricing information and quality benchmarking data through public sources such as the internet, local newspapers, public agencies, and to referral sources. UHC employs the services of UniHealth Select to interface with all private payors. UniHealth has negotiated standard rates with commercial payors for all of United Home Care's agencies. UHC of South West Georgia will be incorporated into this structure. UHC is also committed to utilizing information technology platforms that allow for the sharing of information required to implement these transparency initiatives. Stale of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 6 Rule 111-2-2-.09(h): Positive Relationship with Healthcare Delivery System Intrepid provides little evidence of existing relationships or proposed community linkages within SSDR 8. By contrast, UHC of South West Georgia provides documentation of significant support from organizations and individuals within SSDR 8. Additionally, UHC of South West Georgia's affiliated organizations will work with it to develop an integrated service delivery model capable of sharing information and coordinating services. UHC's affiliated SOURCE program, which works with many providers of all levels of care and with a number of medical professionals, has agreed to incorporate UHC into its existing network and assist UHC in developing relationships with other existing members of the health care community in SSDR 8. Rule 111-2-2-.09(/): Rule 111-2-2-.32(3 )(h): Clinical Needs of Health Professionals Ability to Recruit and Retain Qualified Staff Intrepid does not indicate that it has or plans to have any relationship with local clinical health training programs. Furthermore, Intrepid does not demonstrate that it will have relationships in place to recruit required clinical staff or address the health manpower shortages in SSDR 8. By contrast, UHC of South West Georgia will work closely with Georgia Southwestern State University to offer local preceptorship programs and, should it receive the Certificate of Need award, will offer a $15,000 scholarship for students in clinical training programs. UHC, through its parent and affiliated organizations, has extensive corporate training programs, numerous scholarship and grant programs, cross-organizational advancement opportunities, and employee assistance programs in place that will encourage the retention of qualified staff. UHC of South West Georgia has also committed to work closely with the regional Area Health Education Center (AHEC) to address health manpower shortages through its community-based initiatives. On a comparative basis, UHC of South West Georgia best meets both the general and service specific review considerations and should be given favorable consideration in the review of the competing applications in SSDR 8. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 9 ~. GlOIGlA DUAI'l'MENT OF ".&))J COMMUNITY HEALTH MASTER fILE Rhonda M Medows, MD, Commissioner Sonny Perdue, Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov March 13, 2007 William H. Edwards, COO Intrepid USA Healthcare Services 6600 Frances Avenue South, Suite 510 Edina, MN 55435 Dear Mr. Edwards: The Georgia Department of Community Health, Division of Health Planning has completed its review of the request by F.C. of Georgia, Inc. as outlined in Project GA.2006-131 to establish new home health services in Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor counties in State Service Delivery Region 8. The total estimated cost of this project is $70,000. . Findings and conclusions related to the evaluation of this project are attached to this notice: In accordance with Rule 111-2-2-.07(2)(bJ of the State Certificate of Need Law, it is the determination of the Department of Community Health, Division of Health Planning that the proposal is not consistent with the considerations, standards, and criteria applicable to the issuance of a Certificate of Need. Therefore, your request is hereby denied. This action is subject to appeal, provided the request is received in writing within thirty (30) days of the date of this letter. Please direct your request to: Chairperson State Health Planning Review Board 2 Peachtree Street, NW 5th Floor Atlanta, Georgia 30303-3142 Robert Rozier, Executive Director Division of Health Planning cc: Newell D. Yarborough, Jr., Yarborough Consulting, Inc. Director, Division of Medical Assistance Architect, State of Georgia Health Care Section, Office of Regulatory Services Equal Opportunity Employer GEORGIA DEPARTMENT OF COMMUNITY HEALTH DmSION OF HEALTH PLANNING evALUATION FOR CERTIFICATE OF NEED HOME HEALTH BATCHING CYCLE SSDR 8 PROJECT No.: GA. 2006-130 AMEDISYS HOME HEALTH OF MACON PROJECT No.: GA. 2006-131 INTREPID USA HEAL THCARE SERVICES PROJECT No.: GA. 2006-132 UNITED HOME CARE OF SOUTHWEST GEORGIA BACKGROUND Home Health services enable health care, medical care, social support services and other therapies to be delivered to indMduals in their place of residence. Rule 111-2-2-.32(2J(aJ defines a home health agency as a private organization, or a subdMsion of such an agency or organization, which is primarily engaged in providing care to individuals who are under a written plan of care of a physician; on a visiting basis in the place of residence used as such individual's home; part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse; and one or more of the following services: physical therapy, occupational therapy, speech therapy, medical-social services under the direction of a physician, or part-time or intermittent services of a home health aide. PROJECT OVERVIEW The Division of Health Planning (DMsion) published a Batching Review Cycle Notification for Home Health Services on September 14, 2006. This notification outlined the numerical need for home health services in applicable state service delivery regions. In addition, the notice outlined the following components of the review process: · Procedures for filing notices of intent · Procedures for obtaining application forms · Data survey requirements · Filing fee requirements · Submission of Certificate of Need (CON) applications · Procedures of the review cycle All parties interested in applying under the numerical need provisions were required to file a written notice of intent with the Division by 5:00 pm on October 16, 2006. Applicants were required to include a defined geographic service area consistent with Rule 111-2-2-.32(2J(cJ in their intent notice. CON applications were due to the Department by 12:00 pm on November 13, 2006 in order to be included in the current batching cycle. The numerical need for state service delivery region (SSDR) 8 authorized the consideration of applications for new and expanded home health services. In response, three (3) agencies submitted requests to the Georgia Department of COmmunity Health, DMsion of Health Planning for issuance of Certificates of Need for home health services in SSDR 8. The applicants are described as follows: Amedisvs Georoia, LLe d/b/a Amedisvs Home Health of Macon Amedisys Home Health of Macon ("Amedisys") has requested a Certificate of Need to expand its home health agency into the following Counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Stewart, Sumter and Talbot. These Counties show a need for 621 patients. Amedisys currently serves Taylor, Schley and Muscogee counties in SSDR 8. The total estimated cost for the proposed project is $125,000. Intrepid USA Healthcare Services, Inc Intrepid USA Healthcare Services, Inc ("Intrepid") has requested a Certificate of Need to establish a new home health agency to serve the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley! Stewart! Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of $70,000. United Home Care of South West Georoia, Inc. United Home care of South West Georgia, Inc ("UHC") has requested a Certificate of Need to establish a new home health agency to service the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley! Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of $228,363. PROJECT evALUATION The proposals submitted by Amedisys, Intrepid and UHC were reviewed according to the relevant Certificate of Need rules outlined in the General Review Considerations and Home Health Services Addendum of the Georgia State Health Plan. The following are the review findings for each of these rules. General Review Considerations Rule 111-2-2-.09(lJ(bJ; The population residing in the area servect or to be servect by the new institutional health service has a need for such services. The Home Health Services Component Plan establishes an objective need methodology for home health services based on the utilization of services by different age cohorts. Projected future need is determined by an established rate for a defined population cohort. Projected service capacity is then subtracted from the projected need to determine unmet need. This need methodology is outlined in Rule 111-2-2-.32(3J(aJof the state Certificate of Need law. The Division of Health Planning issued a Batching Review Cycle Notification for Home Health Services on September 14, 2006 in compliance with Rule 111-2-2-.08(1). In this notification, the Division identified a net numerical unmet need of 515 patients in SSDR 8. The sum of only those counties with unmet need in SSDR 8 is 702. The Department authorized the submission of applications for new and expanded home health services in the service delivery region based on the submission criteria outlined in Rule 111-2-2-.32(3J(bJ. Of the sixteen counties in SSDR 8, twelve counties have an unmet need for home health services. The table below lists SSDR 8 counties and their corresponding numerical need as determined by the Division of Health Planning. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 2 Exhibit One. Need for Home Health Services in SSDR 8 By Countv. upQl~N~itQI"..~~~fI~~~~~~ .. .. . . .. 550",8. . . County Need Chattahoochee 94 Clay 58 Harris 204 Macon 58 Marion 33 Ouitman 21 Randolph 27 Schley 35 Stewart 12 Sumter 75 Talbot 39 Taylor 39 Total 702 Source: DMsion of Health Planning Batching Review Cyde Notification September 14, 2006. Based on the numerical unmet need of 515, the Department has authorized new and expanded home health services in SSDR 8. All applicants have proposed to meet the threshold need for new or expanded home health services by Year 2 in their pro forma. All applicants meet the criteria of this rule individually. Home Health Addendum Rule 111-2-2-.32(3){a): The need for a new or expanded home health agency shall be determined through application of a numerical need method and an assessment of the projected number of patients to be served by existing agencies. 1. The numerical need for a new or expanded home health agency in any planning area in the horizon year shall be based on the estimated number of annual home health patients within each planning area as determined by a population-based formula which is a sum of the following for each county within the health planning area: (i) a ratio of 4 patients per 1/000 projected horizon year resident population age 17 and younger; (ii) a ratio of 5 patients per 1/000 projected horizon year resident population age 18 through 64; (iii) a ratio of 45 patients per 1/000 projected horizon year resident population age 65 through 79; and (ivy a ratio of 185 patients per 1/000 projected horizon year resident population age 80 and older. 2. The net numerical unmet need for home health services shall be determined by subtracting the projected number of patients for the current calendar year from the projected need for services as calculated in (3)(a)(l). The projected number of patients for the current calendar year is determined by multiplying the number of patients having received SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 3 services in each coun~ as reported in the most recent survey year, by the county population change factor. The county population change factor is the percent change in total population between the most recent survey year and the current calendar year. As discussed in the evaluation of Rule 111-2-2-.09(1)(b), the Division has determined a net numerical unmet need of 515 patients and an unmet need of 702 patients in SSDR 8 based on the need methodology outlined in this Rule. Intrepid and UHC have requested to establish new agencies and Amedisys has requested to expand their service area. All applicants have proposed to meet the requested threshold need by year two of implementation for the counties for which they have applied. Coun Chattahoochee Clay Harris Macon Marion Quitman Randolph Schley Stewart Sumter Talbot Taylor Total Need 94 58 204 58 33 21 27 35 12 75 39 46 702 94 58 204 58 33 21 27 35 12 75 39 46 702 All applicants individually meet the criteria of this rule. UHC 94 58 204 58 33 21 27 35 12 75 39 46 702 Rule 111-2-2-.32(3)(b): 1. The Division shall accept applications for review as enumerated below: (i) If the net numerical unmet need in a given planning area is 250 patients or more, the Department shall authorize the submission of applications for an expanded home health agency; or (ii) If the numerical unmet need in a given planning area is 500 patients or more, the Department shall authorize the submission of applications for a new home health agency as well as an expanded home health agency. 2. An applicant must propose to provide service only within a geographic service area comprised of a county or group of counties, each of which reflects a numerical unmet need, and contained within the given planning area for which the Department has authorized the submission of applications. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 4 3. The Department shall only approve applications in which the applicant has applied to serve all of the unmet numerical need in anyone county in which need is projected. The need within counties shall not be divided or shared between any two or more applicants. As discussed in the evaluation of Rule 111-2-2-.09(b), the Department has determined that there is a need for the proposed project. Intrepid and UHC have requested to establish new home health agendes. Amedisys has requested to expand its existing service area into counties reflecting need. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3){C): The Division may authorize an exception to Rule 111-2-2-.32(3){a) if: 1. the applicant for a new or expanded home health agency can show that there is limited access in the proposed geographic service area for special groups such as, but not limited to, medically fragile chIldren, newborns and their mothers, and HIV/AIDS patients. For purposes of this exception, an applicant shall be required to document, using population, service, special needs and/or disease incidence rates, a projected need for services in the planning area of at least 200 patients within a defined geographic service area. A successful applicant applying under this section will be restricted to serving the special group or groups identified in the application within the county or counties stipulated in the application; or 2. a particular county is served by no more than two (2) home health agencies and less than one percent of the county's population has received home health services, or the agendes have demonstrated a failure to adequately serve Medicaid patients as evidenced by a level of service to such individuals that is less than the statewide average, within each of the past two years as reported on the Annual Home Health Services survey. For purposes of this exception, an applicant must already be approved to provide service in a contiguous county or be approved to provide service in a county which is no further than 15 miles from the county authorized through the exception. In all other aspects of the application process, the applicant shall be required to comply with provisions applicable to expanded home health agencies. None of the applicants included in the current hatching review cycle for SSDR 8 has applied for a Home Health Services exception as defined in this Rule. The criteria of this rule are not applicable to the proposed projects. Rule 111-2-2-.32(3)(d): An applicant for a new or expanded home health agency shall provide a community linkage plan which demonstrates factors such as, but not limited to, referral arrangements with appropriate services of the health care system and working agreements with other related community services assuring continuity of care focusing on coordinated, integrated systems which promote continuity rather than SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 5 acute, episodic care. Working agreements with other related community services may indude the ability to streamline referrals to other appropriate services and to participate in the development of cross-continuum care plans with other providers. Increasing concern with continuity of care makes it imperative that attention be focused on coordinated care. Among factors influencing continuity of care is the expectation that higher acuity care will be provided by home health agencies. This prospect reinforces the necessity for a community linkage plan that will allow a seamless transition of high acuity patients to an appropriate level of care. As such, the Department requested in the Sixty Day meeting that all applicants in this competitive review process provide a detailed plan and discussion of efforts made to foster community linkages. Amedisvs Amedisys stated that its organization has developed working agreements and referral arrangements with other providers in the communities in which it serves. The applicant provided documentation of a recent acquisition of a therapy staffing company that is expected to serve Amedisys on a company wide basis. Additionally, a personnel contract agreement for physical therapy services was submitted as evidence of the applicanfs current ability to readily obtain these services. Letters of support were also submitted from practitioners, assisted living facilities and organizations that typically serve populations with the greatest potential for needing home health care within the service area. Furthermore, the applicant noted that its organization holds positions, which relate to the ongoing development of community linkages. These positions are required to work with all appropriate staff and other members in the health care community to promote quality healthcare services, as well as to plan and execute special events, which serve to advance staff, patient, and community relations. The Department reviewed the trend in patient volume at Amedisys over the past two years for a sense of the effectiveness of its community linkage relationships. Between 2003 and 2005 the total patient visits from its SSDR 8 service area counties (Schley! and Taylor) increased from 90 to 295. Intreoid Intrepid provided a phased framework for developing community linkages in the proposed service area induding a detailed implementation plan. Letters of support were submitted from practitioners, and various organizations. Intrepid also provided a detailed log of contacts made with various providers and the outcomes as evidence of its intent to establish reciprocal referral agreements. UHC As a part of a large and vertically integrated health system, UHC documented its access to a full continuum of healthcare services as evidence of its ability to ensure continuity of care. The applicant provided copies of its Client Transfer Agreements with each of the existing intra-network facilities and agencies that have been established. Arguably, this intra-network working relationship would offer great assurance of UHC's ability to develop a streamlined, cross continuum referral base. UHC provided a Community Unkage Plan outlining the local organizations and practitioners it has contacted to develop linkages in the service area. The plan provided a framework for increasing public awareness of its services, means of access and to encourage utilization. Letters of support were provided. The Department finds that community linkage plans and efforts presented by all applicants meet the requirements to develop continuity of care within their respective service areas and All applicants minimally meet the criteria of this rule. 1 Schley County was licensed in September 2004. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 6 ." Rule 111-2-2-.32(3)(e): An applicant for a new or expanded home health agency shall provide a written statement of its intent to comply with all appropriate licensure requirements and operational procedures required by the Office of Regulatory Services of the Georgia Department of Human Resources. Home Health facilities in Georgia are required to meet minimum operational standards in order to ensure that citizens receive a quality level of service. These standards are defined in the licensure rules and operational procedures established by the Georgia Department of Human Resources, Office of Regulatory Services. All applicants in the current batching review cycle for SSDR 8 have stated their intent to comply with appropriate licensure requirements and operational procedures. All applicants meet the criteria of this rule Rule 111-2-2-.32(3)((}: An applicant for a new or expanded home health agency or agency(ies) owned and/or operated by the applicant or its parent organization shall have no history of uncorrected or repeated conditional level violations or uncorrected standard deficiencies as identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. All applicants affirm that neither they, nor their parent organization have a history of uncorrected or repeated conditional level deficiencies or uncorrected standard deficiencies as identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. Applicants provided documentation from the Department of Human Resources, which verifies that none have uncorrected regulatory deficiencies. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(g): An applicant for a new or expanded home health agency or agency(ies) owned and/or operated by the applicant or its parent organization shall have no previous conviction of Medicaid or Medicare fraud. All applicants have affirmed that neither they nor their parent organizations have previous convictions of Medicaid or Medicare fraud. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(h): An applicant for a new or expanded home health agency shall provide a written plan which demonstrates the intent and ability to recruit hire and retain the appropriate numbers of qualified personnel to meet the requirements of the services proposed to be provided and that such personnel are available in the proposed geographic service area. A new or expanded home health agency should have in place a plan, which specifies measurable strategies for staff selection, training and retention. In order to promote improved outcomes for consumers, providers must focus on staff. The chart below details the projected full-time equivalent (FTE) staffing needs by Year 2 of project implementation. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 7 Exhibit Three. Projected Staffing by Year Two 40 10 30 20 o . A II S ta ff m N u rs e s 19.35 4.70 In tre p id 33.96 4.69 UHC 14.39 4.23 Am e d is y s * Source: Home Health Batching Applications, SSDR 8 *Based on projected incremental staffing needs for the proposed expansion. Organizational total staff to nurse ratio is 74 to 15.9. Amedisys projects 1,543 incremental visits per nurse by year two of implementation, or approximately 5.92 visits per nurse per day. Intrepid and UHC project 1300 visits annually or 4 visits per nurse daily and 1153 visits annually or 4.4 visits per nurse daily, respectively. All applicants have developed recruitment and retention strategies for both full time and contract staff. The applicants intend to recruit the majority of staff from local resources, including the pool of part-time and non-working nursing professionals, community service agencies, medical equipment firms, other healthcare providers, and area colleges. In addition, applicants will utilize networking relationships established through their parent organizations to recruit staff. Retention efforts will focus primarily on quality improvement and continuing education/training. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3J(iJ: An applicant for a new home health agency shall provide evidence of the intent to meet the appropriate accreditation requirements of the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc. (CHAP), and/or other appropriate accrediting agency. Accreditation by a recognized body such as JCAHO, CHAP and/or other appropriate accrediting agency indicates that an organization meets certain performance standards that enable it to provide quality patient care. As new home health applicants, Intrepid and UHC have stated their intent to seek accreditation from an appropriate accrediting organization, given approval. Intrepid submitted a copy of a letter addressed to CHAP regarding its intent to apply for accreditation as evidence. UHC provided documentation of the current accreditation status of United. Home Care, Inc. as evidence of its ability to be compliant with this standard. However, the documentation provided by UHC reflects a conditional accreditation status for failure to meet select accreditation standards. Although UHC is proposing to establish a new agency in the service area, the inability of its existing operations to obtain full accreditation, as required by Rule 111-2-2-.32(3J{(J., makes its own accreditation prospects dubious. Consequently, UHC failed to provide sufficient evidence of its ability to meet the appropriate accreditation requirements. 2 Based on an average of 260 days per year, excluding holidays and other non-work days. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 8 Intrepid meets the criteria of this rule. UHC does not meet the criteria of this rule. This rule is not applicable to Amedisys. Rule 111-2-2-.32(3Jfi): An applicant for an expanded home health agency shall provide documentation that they are fully accredited by the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc. (CHAP), and/or other appropriate accrediting agency. As noted in the evaluation of the previous rule, accreditation by a recognized body indicates that an organization meets certain performance standards that enable it to provide quality patient care. As the two major accreditation bodies{ JCAHO and CHAP are recognized nationally for standards that reflect high-level performance expectations. In order to ensure that such a level of quality exists in home health services that are awarded a CON, accreditation by such a body is required for the expansion of existing home health agencies. Amedisys submitted documentation of their accreditation from JCAHO and provided documentation of its efforts toward re-accreditation. Amedisys meets the criteria of this rule. This rule is not applicable to Intrepid and UHC Rule 111-2-2-.32{3J(kJ: An applicant for a new or expanded home health agency shall provide its existing or proposed plan for a comprehensive quality improvement program. The Home Health Services Component Plan states that providers should have quality improvement programs consisting of outcomes data and up-to-date industry benchmarks that address patient outcomes, consumer satisfaction and demand{ and patient/consumer rights. All applicants provided adequate plans for comprehensive quality improvement programs consisting of an integrated and systematic approach to monitoring{ evaluating and reporting quality of patient services. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3J{IJ: SSDR 8 Home Health Batching Evaluation of Projects An applicant for a new or expanded home health agency shall assure access to services to individuals unable to pay and to all individuals regardless of payment source or circumstances by: (i) providing evidence of written administrative polides that prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or ability to pay; (ii) providing a written commitment that services for indigent and charity patients will be offered at a standard which meets or exceeds three percent of annua~ adjusted gross revenues for the home health agency or, in the case of an applicant providing other health services, the applicant may request that the Division allow the commitment for March 13, 2007 Page 9 services to indigent and charity patients to be applied to the entire facility; (iii) providing documentation of the demonstrated petformance of the applicant, and any facility in Georgia owned or operated by the applican~s parent organization, of providing services to Medicare, Medicaict and indigent and charity patients; (iv) providing a written commitment to participate in the Medicare, Medicaid and PeachCare programs; and (v) providing a written commitment to participate in any other state health benefits insurance programs for which the home health service is eligible. Rule 111-2-2-.09(1 )(9); The new institutional health service proposed is reasonably finandally 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, seJV handicap, colo~ creect or ethnic affiliation. The Department is required to evaluate the extent to which applicants are financially and physically accessible to the residents of their service area. This evaluation includes an assessment of plans for the provision of services to low income and medically indigent patients and Medicare/Medicaid recipients. In addition, the Department analyzes applicants in terms of compliance with existing indigent and charity care commitments, if any; Medicare and Medicaid utilization levels in comparison to planning area and statewide levels; and community outreach efforts. The Department utilizes a standard of three (3) percent of adjusted gross revenues as an acceptable level of indigent and charity care. All applicants provided copies of administrative policies designed to prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or ability to pay. Additionally, all applicants stated their intent to continue to participate in the Medicare and Medicaid programs and stipulated their commitment to participate in any other state health benefit insurance programs for which home health services are eligible. In addition to the review of administrative polices, the Department evaluates the level of services to Medicare and Medicaid patients. Amedisys Home Health of Macon is proposing to expand its two county service area in SSDR 8; the Macon agency has an established record of performance in the home health industry in other service areas in the state of Georgia. While its service area consists primarily of SSDR 6 counties, 94.3 percent of total visits for Amedisys were Medicare and 2.0 percent of visits were Medicaid. The two active SSDR 8 service area counties are included in these figures. The Department also reviewed the corporate-wide performance of Amedisys, Inc. to evaluate its historical Medicare and Medicaid utilization. In 2005, Amedisys, Inc., which consists of thirteen (13) agencies statewide had 91.3 percent Medicare visits, while Medicaid accounted for 2.8 percent of visits. Similarly, the Department reviewed the Medicare and Medicaid utilization for agencies affiliated with Intrepid. Of the three agencies in operation in 2005, 82.4 percent of total visits were Medicare and 5.5 percent Medicaid. UHS proposes to establish a new agency in SSDR 8, however, in 2005, 90.4 percent of the total visits conducted by its affiliate UHS-Pruitt were Medicare patients, while 2.7 percent of visits were Medicaid patients. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 10 Medicare and Medicaid utilization for SSDR 8 was 83.0 percent and 5.6 percent of visits respectively. In the state of Georgia, Medicare accounted for 81.3 percent of total home health visits while there was a reported 6.4 percent Medicaid visits. Exhibit Four. 2005 Medicare and Medicaid Utilization 100 80 60 40 20 o . M ed ic are IlIIMedicaid Am e d is y s 91.3 2.8 Intrepid 82.4 5.5 UH S.P ruitt 90.4 2.7 Source:2005 Annual Home Health Survey Data reflects the historical performance of affiliated agencies. In evaluating finandal accessibility, the Department evaluates the applicant's level of indigent and charity care commitment for the previous three (3) years. Historically the provision of indigent and charity care by home health agencies has been less than the mandatory 3 percent commitment. The extent of coverage and reimbursement through Medicare and Medicaid programs and poor patient tracking and categorization have arguably been deemed contributing factors to the low indigent and charity care performance in home health agencies. As such, all applicants were asked to submit a plan for providing the committed level of indigent and charity care services at the Sixty Day meeting. Amedisys Data from the Division of Health Planning reflects that the indigent and charity care performance of Amedisys has mirrored that of most other home health agendes, accounting for only 0.04 percent of its adjusted gross revenues in 2004 and 0.01 percent in 2003. However, in 2005, Amedisys was one of only two agencies in SSDR 8 to meet its 3 percent commitment though the direct provision of care. Amedisys argues that its historically low indigent and charity performance was largely due to poor accounting of indigent and charity care patients. The applicant identified cases where patients who should have been categorized as indigent or charity patients were included in bad debt accounts. Amedisys ascertains that improving its accounting and tracking system will improve its record of indigent and charity care performance for all of its affiliated agencies. Amedisys revised and implemented a new Indigent and Charity Care Policy. Amedisys credits this policy and other operational changes with its ability to meet its indigent and charity care commitment directly. Additionally, there has been a reduction in the shortfall amounts for the affiliated agencies. In 2003, Amedisys had one indigent and charity care commitment which resulted in a shortfall of $17,029. By 2004 the shortfall amount skyrocketed to $291,581 for three active commitments. For 2005, the shortfall amount leveled out at $20,704 for six active commitments. The reduction in shortfall payments is due to concerted efforts by Amedisys to locate indigent and charity patients and to appropriately document the care provided. Amedisys will target and promote its services to providers serving the indigent and charity care population to ensure that it meets its commitments in the future. These efforts by Amedisys are outlined in a restated comprehensive Indigent and Charity Care policy. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 11 IntreDid Intrepid discussed the unpredictability of the payor class of patients referred for home health services and the difficulty that exists in attracting indigent and charity care patients in a service area supported by a large hospital based home health agency, as is SSDR 8. Nonetheless, Intrepid renders its commitment of at least 3 percent of its AGR to serve this group. Intrepid's plan to meet this goal consists largely of organizational initiatives through the development of special committees to develop methods and processes of identifying and servicing these patients. Additionally, Intrepid asserts that its marketing efforts in the area will include a statement of its commitment to providing care to indigent and charity patients. The agency will also incorporate this commitment into staff functions and training to ensure that it is properly promoted at all points of access to patients. Despite these planned measures, affiliated agencies have provided little to no indigent care in other service regions. In SSDRs 10, 11 and 12, Intrepid provided a dismal .01 percent, 0 percent and 0.25 percent, respectively in 2005. UHC UHC plans to implement a comprehensive indigent and charity care plan. UHC plans to inform patients and consumers at large about the availability of its program through the admissions process and marketing strategies through the use of informational flyers. As evidence of its commitment to serve the indigent, UHC's indigent and charity care plan will be implemented on a corporate-wide basis. UHC projects that revisions made to its indigent and charity care plan will improve its historical provision of care to this underserved population. Between 2003 and 2005, UHC agencies have provided very limited indigent and charity care. During this time, none of UHC's agencies met their commitments through the direct provision of care. Instead UHC paid an average of $122,385 in shortfall payments to fulfill its obligations. Although, the provision of indigent and charity care by home health agencies has been less than the mandatory three percent (3%) commitment, the Department continues to monitor the performance of agencies, which desire expansion or to establish a new agency. The Department preference is that home health agencies provide the committed level of indigent and charity care services, which is the crux of the commitment, versus paying timely monetary shortfalls. In summary, the Department finds that Amedisys has demonstrated its ability to provide a larger portion of indigent and charity care to its current patient population, thus, Amedisys is found to be financially and physically accessible to the population it proposes to serve. Conversely, as Intrepid and UHC have historically provided limited indigent and charity care, the Department found that Intrepid and UHC are not as financially and physically accessible as Amedisys. The Department notes that it will continue to monitor the indigent and charity care performance of Intrepid and UHC. All applicants minimally meet the criteria of these rules. Rule 111-2-2-.32(3Jm: An applicant for a new or expanded home health agency shall demonstrate that their proposed charges compare favorably with the charges of existing home health agencies in the same geographic service area. All applicants have projected that the majority of their services will be rendered to Medicare patients. Given the fixed rate prospective payment system that has been implemented for Medicare reimbursement, all agencies in the service area will be paid at the same rate regardless of their charge structure. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 12 Exhibit Five. Projected Average Charge by Year Two of Implementation. $170 $160 $150 $140 $130 $12'0 A m e d is y s Intrepid UHC SSDR 8 Source: CON Home Health ADDlications.GA2oo6-130. GA2006-131. GA2oo6-132 and 2005 Home Health Aaency SUNev All applicants meet the criteria of this rule. Rule 111-2-2-.32(3J(nJ; An applicant for a new or expanded home health agency shall document an agreement to provide Division requested information and statistical data related to the operation and provision of home health services and to report that data to the Division in the time frame and format requested by the Division. Uniform data is important to assess changing patterns and projected service needs relevant to the provision of home health services. Furthermore, data enables the Division to analyze quality, patient outcomes, and community benefit. A new or expanded home health agency must provide the Division with requested information and statistical data related to the operation and provision of home health services. All applicants have stated their intent to provide information and data related to their home health services in the required time frame and format requested by the Division. Additionally, UHS- Pruitt stated its willingness to continue to assist the Department in various initiatives to examine the key issues affecting the delivery of long term care services. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(oJ: The Department may authorize an existing home health agency to transfer one county or several counties to another existing home health agency without either agency being required to apply for a new or expanded certificate of need, provided the following conditions are met: (i) the two agencies agree to the transfer and submit such agreement and a joint request to transfer in writing to the department at least thirty (30) days prior to the proposed effective date of the transfer; (ii) the two agencies document within the written request that the transfer would result in increased and improved services for the residents of the county or counties including Medicare and Medicaid patients; (iii) the agency to which the county or counties are being transferred currently offers services in at least one contiguous county or within SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 13 the state service delivery region(s) in which county or counties are located; and (iv) the two agencies are in compliance with all other requirements of these rules; such compliance to be evaluated with the written transfer request. No such transfer shall become effective without written approval from the department. The proposed projects do not involve the consolidation of services through acquisition of an existing agency, transfer of counties between agencies or the merger of agencies. The criteria of this rule are not applicable to the proposed project. General Review Considerations continued 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. According to information compiled from the 2005 Annual Home Health Survey, there were seventeen3 (17) home health providers serving SSDR 8. These agencies provided 112,251 visits to 6,048 patients. Despite the existence of these agencies and the level of home health care services provided, the Division has determined an unmet need for home health services in twelve (12) counties of SSDR 8 based on the need methodology outlined in Rule 111-2-2-.32(3)(a). Rule 111-2-2-.09(1J(c): Given that the Department has identified an unmet need for home health services, there are no existing alternatives to the proposals submitted by the applicants. All applicants meet the criteria of this rule. Rule 111-2-2-.09(1J(d): The project can be adequately financed and is, in the intermediate and long-term, financially feasible. Amedisvs Amedisys estimates a total project cost of $125,000. The propOsed project will be financed through cash reserves. John Giblin, Chief Executive Officer of Amedisys, Inc, verified the availability of funding. Additionally, the applicant submitted financial statements to further substantiate fund availability. Amedisys anticipates that the project will be implemented in July 2007. By Year 2, the applicant projects net income of $386,207. The applicant's pro forma reflects 621 additional patients served by Year 2 of the expansion project for a total of 2,112 patients. Intrepid Intrepid estimates a total project cost of $70,000. The proposed project will be financed through unrestricted cash on hand. Gregory Von Arx, Chief Financial Officer of Intrepid Healthcare USA, verified the availability of funds. Additionally, the applicant submitted un-audited financial statements 3 Access Home Health in Muscogee County, closed on September 7,2005. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 14 for Intrepid USA Healthcare Services and Intrepid USA Inc. Financials for Intrepid USA Healthcare Services reflect a net loss by the end of fiscal year 2006. Financial statements for Intrepid USA, Inc. reflect a profit during the same period that could adequately fund the project. The applicant stipulates that all home health agencies do business as Intrepid USA Healthcare Services. The applicant anticipates that the project will be implemented by July 2007. By year 2, the applicant projects to serve 702 patients. UHC UHC estimates a total project cost of $228,363. The proposed expansion will be financed through unrestricted reserves on hand. The applicant submitted its most recent financial statement and a letter from Chief Executive Officer, Greg Wren, to verify the availability of funding. UHC anticipates that the project will be implemented no later than July 2007. The pro forma projections for Year 2 indicate a net income of $89,713 and service to 702 patients. The proposals submitted by Amedisys, Intrepid and UHC are adequately financed and found to be reasonably financially feasible, based on the assumptions provided. All applicants meet the criteria of this rule. Rule 111-2-2-.09(n(eJ: The effects of the new institutional health service on payors for health services, including governmental payors, are not unreasonable. As discussed in the evaluation of Rule 111-2-2-.32(3J(mJ, the fixed rate prospective payment system of Medicare ensures that all home health providers in a geographic service area are reimbursed for their services at the same amount, regardless of charges. Therefore, the services proposed by the applicants in the batching review cyde for SSDR 8 are not expected to have an unreasonable effect on payors for health services. In fact, they should alleviate some of the financial constraints for payors of health services because of the mandatory 3% indigent and charity care commitment. However, since the Department found that the project proposed by UHC has not met the requirements of Rule 111-2- 2-.32(3J(iJ. the project proposed by UHC is not found to have reasonable effects on payors for health services in the proposed service area. The institutional health service proposed by Amedisys and Intrepid may serve to make home health services more financially accessible to a variety of payors. Amedisys and Intrepid meet the criteria of this rule. UHC does not meet the criteria of this rule. Rule 111-2-2-.09(nm: 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. The nature of home health services requires that the majority of care be provided in the homes of patients. Consequently, none of the proposed projects involves construction to implement. All the applicants either have existing administrative offices or have proposed leasing office space upon approval. All of the applicants have provided verification of the availability of the proposed sites for their administrative offices and have stated that these sites are properly zoned for the administrative functions of a home health service. The criteria of this rule are not applicable to the proposed projects. Rule 111-2-2-.09(n(hJ: The proposed new institutional health service has a positive relationship to the existing health care delivery system in the service area. SSOR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 15 Applications for new or expanded home health services were filed in response to a need. identified by the Department, through a batching notice. The proposals as submitted by the applicants are intended to address this identified need. Home health care is a very specific, specialized type of home care that focuses on a specific type of patient, those who are transitioning out of an acute car setting or those who are unable to care for themselves. As such, the lack of available home health care services could potentially lead to greater utilization of more costly long term care alternatives, such as nursing home care, which would ultimately lead to an increase in health care costs in general. New institutional health services that fundamentally meet the rule criteria can be reasonably expected to have a positive relationship to the existing health care delivery system in the service area. However, since the Department determined that UHC failed to meet the criteria of Rule 111-2-2-.32(3)(;), it will not have a positive effect on the existing health care delivery system. In factI the limitation of care to the indigent and the potential inability to fully meet quality of care standards may be a detrimental hindrance to the effective delivery of home health care services in the region. Amedisys and Intrepid meet the criteria of this rule. UHC does not meet the criteria of the rule Rule 111-2-2-.09(1Jro: 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. This criterion is not applicable to home health projects.. Rule 111-2-2-.09(1J(k): The proposed new institutional health service conducts biomedical or behavioral research projects or a new service development, which is designed to meet a nationa~ regiona~ or a statewide need. The applicants will not conduct biomedical or behavioral research projects or develop any new service. The criterion of this rule is not applicable to the proposed project. Rule 111-2-2-.09(1Jm: The proposed new institutional health service meets the clinical needs of health professional programs which request assistance. All applicants indicate their intent to provide assistance to health professional programs as requested. Amedisys indicated its provision of classroom instruction at nursing and other professional schools in the Macon area and its intent to expand such efforts in SSDR 8. Amedisys also serves as a clinical rotation site for nursing schools at an area university. Ukewise, UHC discussed its organizational wide commitment to assisting health professional programs meet their clinical needs through the provision of scholarships and planned implementation of a local preceptor program. All applicants meet the criteria of this rule. Rule 111-2-2-.09(1)(m): 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. Home health care by its very nature is a more cost effective alternative in healthcare as is evidenced by the proposed costs and charges. Amedisvs SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 16 Amedisys indicated its recognition by a national organization for its Disease State Management programs for maximizing the recovery and functionality of its patients as evidence of the improvements it has made in health care delivery. Intrepid Intrepid indicates its low acute care hospitalization rates and clinical programs are some examples of how it intends to improve the delivery of care. UHC UHC identified several initiatives through which it plans to garner improvements to health care delivery. The system-wide plan for improving financial access, adaptation of programs for the monitoring and benchmarking of quality standards, utilization of a linked network of computers and increasing public access to health care cost and quality information are all expected to improve UHC's delivery of health care. All applicants minimally meet the criteria of this rule. Rule 111-2-2-.09(1JrnJ: The proposed new institutional health service fosters the special needs and circumstances of health maintenance organizations. The criteria of this rule are not applicable to the projects proposed by Amedisys, Intrepid and UHC Amedisys and Intrepid have demonstrated their ability to meet the goals of the State Health Plan, at a minimum, as evidenced by the fact that they have met all the criteria of the relevant rules contained in the General Review Considerations and Home Health Services Addendum of the State Health Plan. Consequently, further review under Rule 111-2-2-.08(1 J(hJ is required to determine the best proposal to meet the numerical unmet need in SSDR 8. Rule 111-2-2-.08(1J(hJ: In evaluating batched applications, if any or all of the batched applications equally meet the statutory considerations, priority consideration will be given to a comparison of the applications with regard to: 1. The past and present records of the fadlity, and other existing fadlities in Georgia, if any, owned by the same parent organization, regarding the provision of service to all segments of the population, particularly including Medicare, Medicaid, minority patients and those with limited or no ability to pay; In its evaluation of Rule 111-2-2-.32(3)(1) and Rule 111-2-2-.09(1)(g), the Department discussed the level of Medicare and Medicaid and indigent and charity care provision of the applicants. Although, the provision of indigent and charity care by home health agencies has been less than the mandatory three percent (3%) commitment, the Department continues to monitor the performance of agencies, which desire expansion or to establish a new agency. The Department preference is that home health agencies provide the committed level of indigent and charity care services, which is the crux of the commitment, versus paying timely monetary shortfalls. The Department finds that Amedisys has demonstrated its ability to adequately serve the indigent and charity population as. evidenced by its ability to meet its committed level of care through the direct provision of services. Similarly, Intrepid has demonstrated its ability to provide a higher level of services to the Medicaid population in its current service area. Both applicants have documented their commitment to improving access to these special groups and have submitted plans for better meeting the needs of the indigent population. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 17 Amedisys and Intrepid meet the criteria of this rule. 2. Specific services to be offered; Both applicants are proposing to offer a variety of specialized home care selVices. Amedisys and Intrepid meet the criterion of this rule 3. Appropriateness of the site, i.e, the accessibility to the population to be served, availability of utilities, transportation systems, adequacy of size, cost of acquisition, and cost to develop; As discussed in the evaluation of Rule 111-2-2-.09(1){n. the applicants either have existing administrative offices or have proposed leasing office space upon approval. As such there are no associated acquisition or development costs. Furthermore, home health selVices are delivered to individuals in their place of residence and are thus highly accessible to the population to be selVed. Amedisys and Intrepid meet the criterion of this rule 4. Demonstrated readiness to implement the project, including commitment of financing; To evaluate the applicants' readiness to implement the project, the Department reviewed the availability of funds and the applicant's preparation to develop or expand its selVice in SSDR 8. As discussed in Rule 111-2-2-.09{1J{dJ, the applicants have adequately documented the availability of funds needed to implement the projects as proposed. The strength of an applicants' community linkage plan is indicative of their readiness to implement the proposed project. In the Department's review of Rule 111-2-2-.32(3J{dJ, the applicants provided community linkage plans to demonstrate the steps they have taken to develop relationships in their new selVice areas and a strategy for fostering these relationships in the future. Due to the competitive nature of this process, the strengths of the community linkage plans and efforts exhausted are a significant factor in the review process. As an existing provider of selVices in the region, Amedisys has laid a foundation on which to develop future community linkage relationships within the expanded selVice area as is evidenced by its growing utilization in its limited selVice area. The Department expects Amedisys will continue to have a positive impact on the health care delivery system in SSDR 8. In comparison, the community linkage plan submitted by Intrepid does not adequately demonstrate its ability to establish relationships in the region. Intrepid provided a good faith plan that is speculative in nature, whereas the utilization of selVices provided by Amedisys has demonstrated its ability to establish and maintain community linkage plans. Amedisys best meets this criterion of the rule. Intrepid does not meet this criterion. 5. Patterns of past performance, if any, of the applicants in implementing previously approved projects in a timely fashion; Amedisys provided documentation to reflect the timely implementation of previously approved projects. There is no indication that Intrepid's past performance in implementing previously approved projects has been anything but according to the timeframes as required by the Department. Amedisys and Intrepid meet the criteria of this rule. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 18 6. Past record, if an~ of the applicant facility, and other existing facilities owned by the same parent organization, if an~ in meeting licensure requirements and factors relevant to providing accessible, quality health care; In its evaluation, the Deparbnent reviews the current record of the applicant or affiliate in meeting licensure requirements. The Department has verified that neither applicant has current, uncorrected licensure deficiencies. Amedisys and Intrepid meet the criterion of this rule. 7. Evidence of attention to factors of cost containment, which do not diminish the quality of care or safety of the patient, but which demonstrate sincere efforts to avoid significant costs unrelated to patient care; and Home health care by its very nature is a more cost effective alternative in healthcare as is evidenced by the proposed costs and charges. The proposed counties will allow for the sharing of administrative overhead costs affiliated organizations currently operating in SSDR 8 or in the state, which will serve to lower overall overhead costs. This sharing of resources is expected to enhance administrative productivity while reducing its operating costs for both applicants. Amedisys and Intrepid meet the criterion of this rule. 8. Past compliance, if an~ with survey "and post-approval reporting requirements and indigent and charity care commitments. Amedisys and Intrepid have been compliant with past survey and post approval reporting requirements. In its evaluation of Rule 111-2-2-.(.32J(3J(IJ and Rule 111-2-.09(1)(g), the Department determined that Amedisys, as the only applicant in the batch to meet its indigent and charity commitment through the direct provision of care, has demonstrated its ability to provide a larger portion of care to this special population. In comparison, Intrepid provided only a limited amount of indigent and charity care and thus is not as financially accessible as Amedisys. Amedisys best meets the criteria of this rule. Intrepid does not meet the criteria of this rule Rule 111-2-2-.09(1)(aJ.'The proposed new institutional health services are reasonably consistent with the relevant general goals and objectives of the State Health Plan. The Home Health Services Component Plan states the following goal: "to ensure that Georgia citizens have access to cost-effective, efficient, and quality home health services." Due to the competitive nature of the home health batching review process, the Deparbnent carefully evaluates the proposals to determine the best alternative to meet the needs of the service area. Factors such as historical financial accessibility with regard to indigent and charity care, Medicare and Medicaid provision, community linkages, and quality of service are heavily weighed to determine the project with the optimal benefit to the service area. Amedisys has demonstrated its ability to meet this goal as evidenced by the fact that it has met all the criteria of the relevant rules contained in the General Review Considerations and Home Health Services Addendum of the State Health Plan. Consequently, the proposed services of this agency have been determined to be consistent with the Plan's goals and objectives. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 19 The home health services proposed by Intrepid and UHC have been determined to be inconsistent with the goals and objectives of the State Health Plan, given that both applicants failed the following rules: · UHC :Rule 111-2-2-.32(3J{j) ; Rule 111-2-2-.09(lJ(e); and Rule 111-2-2-.09(1J(hJ: and · Intrepid: Rule 111-2-2-.08(1J(hJ4and Rule 111-2-2-.08(lJ(hJ8 As an experienced Amedisys Home Health of Macon is experienced in working with community referral sources and its existing presence and historical performance in SSDR 8 will serve to facilitate its expansion in the service area. Amedisys provided an extensive community linkage plan and documented its efforts in developing new relationships in the expansion areas. The increasing patient base of Amedisys in its current SSDR 8 service area is a testament to the strength of the community relationships the applicant has been able to develop. Additionally, Amedisys was the highest provider of indigent and charity care in SSDR 8, one of only a few to actually meet its commitment through the direct provision of care. As discussed extensively in the evaluation of Rule 111-2-2-.32(3J(1) and Rule 111-2-2-.09(J)(a), home health agencies have historically had low indigent and charity care performance. Amedisys' performance is indicative of the effectiveness of its efforts to ensure increased financial accessibility of its home health services. Finally, Amedisys has proposed to meet all the need in SSDR 8, except for Schley and Taylor Counties, where it currently provides service. Despite being an existing provider in these counties, the Department's need calculation reflected a need of 35 and 45 patients respectively. Amedisys is only one of eight providers in Schley County. The numerical need as calculated by the Department is based on a projection three years into the future. Therefore the numerical need by itself is not an accurate measure of the current need in the county or the effectiveness of existing agendes to meet that need. The historical utilization of Amedisys indicates that the applicant is in fact meeting the home health service needs for an increasing number of presenters for care. For these reasons and those discussed in this evaluation, Amedisys has been determined to be the superior applicant for the expansion of home health services in SSDR 8. Amedisys meets the criteria of this rule. Intrepid and UHC do not meet the criteria of this rule. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 20 CONCLUSION Amedisys Home Health of Macon, Intrepid USA Healthcare Services and United Home Care have each requested a Certificate of Need to expand or establish new home health services in State Service Delivery Region 8. Based on the evaluation findings of the Certificate of Need Rules relevant to the projects proposed, it is the decision of the Georgia Department of Community Health, Division of Health Planning to ISSUE a Certificate of Need to Amedisys Home Health of Macon to expand its home health services to include Chattahoochee, Oay, Harris, Macon, Marion, Quitman, Randolph, Stewart, Sumter and Talbot.. These Counties show a need for 621 patients. Amedisys currently serves Taylor, Schley and Muscogee counties in SSDR 8. The total estimated cost for the proposed project is $125,000. It is the decision of the Georgia Department of Community Health, Division of Health Planning to DENY a Certificate of Need to Intrepid USH Healthcare Services, Inc to establish a new home health agency to serve the following counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of $70,000. It is the decision of Georgia Department of Community Health, Division of Health Planning to DENY a Certificate of Need to United Home Care of South West Georgia, Inc ("UHC") to establish a new home health agency to service the following counties: Chattahoochee, Oay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of $228,363. Additionally, the certificate is valid for a period of twelve (12) months, unless extended for good cause. It is important that the administration of your project be consistent with the Certificate of Need rules. Accordingly, a copy of "Post Approval Requirements," which outlines the duration, progression, and extension provisions (if needed) that apply to this approval is available at the Department's website: www.georaia.gov. Please be advised that a decision by this Department is subject to appeal within thirty (30) days from the date of this letter. Should a bona fide request for an appeal be received, you will be promptly notified and the Certificate of Need will be suspended until the appeal is resolved. You are strongly advised not to make a substantial obligation of funds until the time period for requesting an appeal has expired. The approval of a project by the Department of Community Health, Division of Health Planning does not assure that any amount or rate of reimbursement will be paid by the Division of Medical Assistance, the Medicare intermediary, or any other payment source. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 21 GEORGIA DEPARTMENT OF COMMUNITY HEALTH FI Rhonda M, Medows, MD, Commissioner Sonny Perdue, Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov March 21, 2007 Writer's Direct Dial 404-656-0655 Honorable Bobby Pace Chairman-Sumter County Commission 605 Spring Street Americus, GA 31709-0295 Dear Honorable Pace: The Georgia Department of Community Health, Office of General Counsel (the Department) has completed a review of an application from: 2006-131 Intrepid USA Healthcare Services Establish New Home Health Agency SSDR 8 (Joined 130,132) Batching Filed: 11/13/2006 Deemed Complete: 11/13/2006 Joined: 11/13/2006 60th Day Deadline: 111212007 Decision Deadline: 3/13/2007 DENIED: 3/13/2007 Site: 1610-D East Forsyth Street, Amer1cus, GA 31709 (Sumter County) Contact: Newell D. Yarborough, Jr. 912-925-5896 Estimated Cost: $70,000 The proposal failed to conform with plans addressing the development of health care facilities and services in Georgia therefore, the Department has denied a Certificate-of- Need to the applicant. The Department reviewed the proposal under Georgia's health planning statute, which seeks to avoid the unnecessary duplication of expensive health care services, equipment and facilities. You may have standing under state law to challenge this decision during an administrative appeal hearing before the Health Planning Review Board or to intervene in any appeal, which may be filed by an aggrieved party. Requests for an appeal should be directed to Chairman, State Health Planning Review Board, Two Peachtree Street, 5th Floor, Atlanta, Georgia 30303-3159. Your request must be received no later than 30 days from the denial date above. This notification is provided for informational purposes in compliance with Georgia's Health Planning Statute, O.C.G.A. Title 31, Chapter 6. Sincerely, ~ ,b, Fredia Bradford Division of Health Planning Office of General Counsel Equal Opportunity Employer GEORGIA DEPARTMENT OF COMMUNITY HEALTH Rhonda M. Medows, MD, Commissioner Sonny Perdue, Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov March 21, 2007 Writer's Direct Dial 404-656-0655 Americus Times Recorder Attention: Editor 101 Highway 27 East P.O. Box 1247 Americus, GA 31709 To The Editor: The Georgia Department of Community Health, Office of General Counsel (the Department) has completed a review of an application from: 2006-131 Intrepid USA Healthcare Services Establish New Home Health Agency SSDR 8 (Joined 130,132) Batching Filed: 11/13/2006 Deemed Complete: 11/13/2006 Joined: 11/13/2006 60th Day Deadline: 111212007 Decision Deadline: 3/13/2007 DENIED: 3/13/2007 Site: 1610-D East Forsyth Street, Americus, GA 31709 (Sumter County) Contact: Newell D. Yarborough, Jr. 912-925-5896 Estimated Cost: $70,000 The proposal failed to conform with plans addressing the development of health care facilities and services in Georgia therefore, the Department has denied a Certificate-of- Need to the applicant. The Department reviewed the proposal under Georgia's health planning statute, which seeks to avoid the unnecessary duplication of expensive health care services, equipment and facilities. You may have standing under state law to challenge this decision during an administrative appeal hearing before the Health Planning Review Board or to intervene in any appeal, which may be filed by an aggrieved party. Requests for an appeal should be directed to Chairman, State Health Planning Review Board, Two Peachtree Street, 5th Floor, Atlanta, Georgia 30303-3159. Your request must be received no later than 30 days from the denial date above. This notification is provided for informational purposes in compliance with Georgia's Health Planning Statute, O.C.G.A. Title 31, Chapter 6. Sincerely, '~ 'D Fredia Bradford Division of Health Planning Office of General Counsel Equal Opportunity Employer GEORGIA DEPARTMENT OF COMMUNITY HEALTH Rhonda M. Medows, MD, Commissioner Sonny Perdue, Governor 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov March 21, 2007 Writer's Direct Dial 404-656-0655 Don R. ten Bensel, Exec. Director Middle Flint RDC 228 W. Lamar Street Americus, GA 31709 Dear Mr. Bensel: The Georgia Department of Community Health, Office of General Counsel (the Department) has completed a review of an application from: 2006-131 Intrepid USA Healthcare Services Establish New Home Health Agency SSDR 8 (Joined 130,132) Batching Filed: 11/13/2006 Deemed Complete: 11/13/2006 Joined: 11/13/2006 60th Day Deadline: 111212007 Decision Deadline: 3/13/2007 DENIED: 3/13/2007 Site: 1610-D East Forsyth Street, Americus, GA 31709 (Sumter County) Contact: Newell D. Yarborough, Jr. 912-925-5896 Estimated Cost: $70,000 The proposal failed to conform with plans addressing the development of health care facilities and services in Georgia therefore, the Department has denied a Certificate-of- Need to the applicant. The Department reviewed the proposal under Georgia's health planning statute, which seeks to avoid the unnecessary duplication of expensive health care services, equipment and facilities. You may have standing under state law to challenge this decision during an administrative appeal hearing before the Health Planning Review Board or to intervene in any appeal, which may be filed by an aggrieved party. Requests for an appeal should be directed to Chairman, State Health Planning Review Board, Two Peachtree Street, 5th Floor, Atlanta, Georgia 30303-3159. Your request must be received no later than 30 days from the denial date above. This notification is provided for informational purposes in compliance with Georgia's Health Planning Statute, O.C.G.A. Title 31, Chapter 6. Sincerely, } -6. Fredia Bradford Division of Health Planning Office of General Counsel Equal Opportunity Employer GEORGIA DEPARTMENT OF COMMUNITY HEALTH 2 Peachtree Street, NW Atlanta, GA 30303-3159 www.dch.georgia.gov Rhonda M. Medows, MD, Commissioner Sonny Perdue, Governor March 21, 2007 Writer's Direct Dial 404-656-0655 Honorable Bill McGowan Mayor of Americus 101 W. Lamar St Americus, GA 31709-3580 Dear Honorable McGowan: The Georgia Department of Community Health, Office of General Counsel (the Department) has completed a review of an application from: 2006-131 Intrepid USA Healthcare Services Establish New Home Health Agency SSDR 8 (Joined 130,132) Batching Filed: 11/13/2006 Deemed Complete: 11/13/2006 Joined: 11/13/2006 60th Day Deadline: 111212007 Decision Deadline: 3/13/2007 DENIED: 3/13/2007 Site: 1610-D East Forsyth Street, Americus, GA 31709 (Sumter County) Contact: Newell D. Yarborough, Jr. 912-925-5896 Estimated Cost: $70,000 The proposal failed to conform with plans addressing the development of health care facilities and services in Georgia therefore, the Department has denied a Certificate-of- Need to the applicant. The Department reviewed the proposal under Georgia's health planning statute, which seeks to avoid the unnecessary duplication of expensive health care services, equipment and facilities. You may have standing under state law to challenge this decision during an administrative appeal hearing before the Health Planning Review Board or to intervene in any appeal, which may be filed by an aggrieved party. Requests for an appeal should be directed to Chairman, State Health Planning Review Board, Two Peachtree Street, 5th Floor, Atlanta, Georgia 30303-3159. Your request must be received no later than 30 days from the denial date above. This notification is provided for informational purposes in compliance with Georgia's Health Planning Statute, O.C.GA Title 31, Chapter 6. Sincerely, 'j- -f) Fredia Bradford Division of Health Planning Office of General Counsel Equal Opportunity Employer Arnall Golden Gregory LLP Direct phone: 404.873.8626 Direct fax: 404.873.8627 E-mail: charles.gregory@agg.com www.agg.com [5) IE. iT; r:; ~ \\n rc rri' ~I c A:R: 11~O; \~ _.-J HEALTH PLANNiNG REViEW BOARD April 11, 2007 VIA HAND DELIVERY Chai rperson State Health Planning Review Board Division of Health Planning Department of Community Health 2 Peachtree Street N.W., 5th Floor Atlanta, GA 30303-3142 Re: United Home Care of Southwest Georgia, Inc., Project No. GA 2006-132 Amedisys Georgia, LLC d/b/a Amedisys Home Health of Macon, Project No. GA 2006-130 Intrepid USA Healthcare Services, Inc., Project No. GA 2006-131 Dear Chairperson: This firm represents United Home Care of Southwest Georgia, Inc. ("United''), a home health provider that filed an application to establish a new home health agency in State Service Delivery Region 8. Its application was denied in a decision letter dated March 13, 2007. The project was joined in a batching cycle with the applications of: . Amedisys Georgia, LLC d/b/a Amedisys Home Health of Macon ("Amedisys"), Project No. GA 2006-130, and . Intrepid USA Healthcare Services, Inc. ("Intrepid"), Project No. GA 2006-131. In the same decision letter, the Department of Community Health, Division of Health Planning, decided to issue a Certificate of Need to Amedisys to expand its home health services and denied the other applications. United is aggrieved by the Department's decision and hereby requests an initial administrative appeal hearing before a hearing officer on the denial of the United application and on the approval of the Amedisys application. United also hereby requests to intervene in any hearing requested by Intrepid. 106283J22092452v2 171171h Street, NW I Suite 2100 I Atlanta. GA 30363-1031 I 404.873.8500 I Fax: 404.873.8S01 I Macon Office: 478.745.3344 Arnall Golden Gregory LLP Chairperson April 11, 2007 Page 2 This request is made pursuant to Review Board Rule 274-1-.03 and O.C.GA 931- 6-44(c). The opposition letters submitted by United are attached hereto as Exhibits uN' and liB", Please let me know if you have any questions. Very truly yours, ARNALL GOLDEN GREGORY LLP Charles L. G:~1oz; CLG:dae Attachments cc: Robert Rozier Scott Shull Kathy T.M. Platt 106283/2 2092452v2 . '~..".'..'... "\\1 G.O.OlADll.A......NTO' .)}. COWMlJNITY HItALTR <:rENTER the Project Number and County below DATE STAMP for the project that you are opposing. Use the Format YVYY-###. PROJECT NUMBER GA 2006 -130 COUNTY: Muscogee Signed Original and 3 Copies (ThIs Box for Division of HlNIlth Planning Use Only) Applicant Name: Amedlsys Georgia, LLC Opposing Party Name: United Home Care of South West Georgia Inc. Georgia Certificate of Need Opposition to Project under Review f,c.~ \ --i L----v General Information: 1. This Opposition form Is a required document that must be submitted by a party wishing to oppose a project currently under consideration by the Department. Anyone may oppose a project, but only certain parties have standing to appeal a project that has been opposed. 2. Pieasll, review this form before attempting to complete and submit the Information requested. 3. This form !!!!!!! be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 4. Ail form fields must be completed. If a field is not applicable, so indicate. 5. Attach your detailed opposition to this form. 6. This form and any and ail attached sheets detailing reasons for opposition to the project under consideration must be submitted to the Department by the appropriate opposition deadline. · Opposition addressing Information contained in the application as originaill submitted by the Applicant must be submitted to the Department no later than the 60 day of the application review cycle; · Opposition addressing information contained in additional information submitted by the applicant prior to the 75th day of the review cycie must be submitted to the Department no iater than the 83rd day of the review cycle; State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Paga1 · Opposition addressing Information contained in an amendment to the project must be submitted to the Department no later than the 8511I day, except when the review cycle of the project Is extended to 120 days, such opposition must be submitted to the Department no later than the 11511I day of the review cycle; · Notwithstanding the timeframes above, opposition to batched applications for home health and nursing facilities, regardless of whether such opposition is to information contained In the original application, an amendment, or additional information, must be submitted to the Department by the 8511I day of the review cycle; and · Notwithstanding the timeframes above, opposition to expedited applications, regardless of whether such opposition is to Information contained in the original application, an amendment, or additional Information, must be submitted to the Department by the 3511I day of the review cycle. 7. Any opposition that is not submitted in a timely fashion as described in the previous paragraph will be returned and will not become part of the master file. 8. You must submit a signed original and three copies of this form and any and ail attached documentation. 9. The signed original Opposition form and the three copies must be submitted on loose leaf, one-sided 81,2 by 11-lnch paper only. Each copy and the original should be rubber banded to separate each copy and the original. · The signed original must not be hole punched nor stapled or otherwise bound. · The three copies must be three-hole-punched but must not be stapled or otherwise bound. 10. Faxed copies of documents and information are not official and must be followed-up with the original documents by the mandated deadline for Inclusion in a project master file. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 2 OPPOSITION 1. Identify the opposing party. OPPOSING PARTY Legal Name: United Home Care of South West Georgia LLC. d/b/a (if applicable): Address: 3945 Lawrenceville Highway City: Lilburn I State: GA I Zip: 30047 2. Identify the authorized representative submitting this opposition. AUTHORIZED REPRESENTATIVE Name: I Title or Position: Address: City: I State: J Zip: Phone: I Fax: E-mail Address: 3. Does the opposing party have legal standing to appeal the application should it be approved? IZI Yes 0 No If YES -+ Complete the following table indicating the Opposing Party's purported standing. If NO -+ Continue to the next Question. You may still submit this opposition. IZI Yes 0 No DYes IZI No o Yes IZI No IZI Yes 0 No Is the Opposing Party a competing applicant? Is the Opposing Party a county or municipal government within whose boundaries the project will be located? Is the Opposing Party a competing health care facility? Is the Opposing Party notifying the Department of its opposition during the required time periods? Will the Opposing Party be aggrieved if the Department were to approve the application? IZI Yes 0 No State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 3 4. Identify the Applicant for the project that you are opposing. APPLICANT INFORMATION Applicant Legal Name: Amedisys Georgia LLC dIbIa (if applicable): Amedisys Home Health of Macon Address: 11100 Mead Road, Suite 300 City: Baton Rouge State: LA I Zip: 70816 County: Baton Rouge Project Number. 2006--130 Title of Applicant's Project: Expansion of a Home Health Agency in SSDR 8 5. Indicate the location of the Information being opposed. Check onlv one of the following: lZIinformation contained in the original submission of the Applicant (Verify that you are submitting your opposition by the Bel" day 01 the review cycle) o Information contained in additional Information submitted by the Applicant (Verify that you are submitting your opposition by the a~ day of the review cycte) o Information contained in an amendment (Verify that you are submitting your opposition by the aft' day of the review cycle) o Information submitted in the original submission, additional information, or an amendment to a batched home health or nursing facility application. (Verify that you are submitting your opposition by the aft' day of the review cycle) o Information submitted in the original submission, additional information, or an amendment to an expedited application. (Verify that you are submitting your opposition by the 3ft' day of the review cycle) 6. Attach 8-1/2 by 11-lnch sheets of paper providing the specific reasons for the opposition to the Applicant's project. Please see the attached. 7. Does the Opposing Party have any lobbyist empioyed, retained, or affiliated with the Opposing Party directly or through its authorized representative? [8J YES 0 NO If YES -+ Please complete the information in the table on the next page for each lobbyist employed, retained, or affiliated with the OpPOSing Party. 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 -+ Continue to the next question. Slate of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 4 LOBBYIST DiSCLOSURE STATEMENT Registered Name of Lobbyist Affiliation with. with State Opposing Party Ethics Commission? Joe Tanner o Employed IZI Ves IZI Other Affiliation DNa Bill Roper o Employed IZI Ves IZI Other Affiliation DNa o Employed Dves o Other Affiliation DNo . o Employed DVes o Other Affiliation DNo o Employed DVes o Other Affiliation DNo o Employed DVes o Other Affiliation DNa o Employed DVes o Other Affiliation DNo o Employed DVes o Other Affiliation DNo 8. Opposing Party Certification. By signing below, I hereby certify that the Contained statements and all attachments hereto are true and complete to the best of my knowledge and belief and that I possess the authority to submit this form and bind the Opposing Party. to promises made herein. Signature N/d 'gnat Name: Neil L. Pruitt, Jr. Title: Chairman & CEO LV}: Date: ?,.. $-0 Submit to: Division of Health Pianning Department of Community Health 2 Peachtree Street, NW - 5'" Floor Atianta, GA 30303 State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2005 Page 5 United Home Care of South West Georgia, Inc. Amedisys Georgia, LLC d/b/a! Amedisys Home Health of Macon Project # 2006-130 United Home Care of South West Georgia, Inc. (UHC of South West Georgia) is a competing applicant through its CON application Project #2006-132. UHe of South West Georgia opposes the application filed by Amedisys Georgia, LLC d/b/a Amedisys Home Health of Macon (Amedisys). Furthermore, UHC of South West Georgia asserts that it is the better applicant to meet the identified need for SSDR 8 for the following reasons: Rule 111-2-2-.09(1)(a): Consistency with the State Health Plan Amedisys fails to meet this general review consideration because it does not adequately address certain other general and service specific rules. Only UHe of South West Georgia proposes to incorporate the proposed agency into an integrated continuum of long term care services which will enhance access and transparency, and promote the delivery of care and service at the most appropriate and cost-effective level of care. UHC of South West Georgia and its parent and affiliates bring vast resources and a vision for how home health services should be provided as part of the larger health system focused on continuously improving quality of care, cost effectiveness of services provided at the appropriate level, and enhancing accessibility of services. This vision, as outlined in its application, is consistent with the goals of the State Health Plan, Governor Perdue's recently stated initiatives related to transparency and choice, and recent CMS initiatives. Only UHe of South West Georgia has fully integrated the Governor's initiatives into its plans. Indeed, it has committed to expand its commitments to access and transparency in cost and quality to its existing agencies as well as the proposed agency. For this reason, UHC of South West Georgia's project better meets the criteria than the other joined applicants. Rule 111-2-2-.09(1)(b): Rule 111-2-2-.32(3)(b): Need for the Proposed Project Needfor a New or Expanded Home Health Agency Compared to UHe of South West Georgia, Amedisys does not best meet the general and service specific rules regarding need because Amedisys does not propose to meet as much of the identified need as UHe of South West Georgia. UHC of South West Georgia proposes to serve all of the counties with identified need. Therefore, UHe of South West Georgia better meets these considerations. Rule 111-2-2-.09(1)( g): Rule 111-2-2-.32(l): Financial Accessibility Financial Accessibility Amedisys projects that self pay patients will not comprise virtually any of gross revenue ($4,775) of the agency in the second year of operation, yet Amedisys projects to write off $245,001 in indigent/charity care. Furthermore, Amedisys has not indicated how it will meet its commitment to indigent/charity care operationally and has not provided for any non-clinical or clinical staff to assist in these efforts. UHC of South West Georgia has provided a detailed plan which includes internet posting of its policies, a specific procedure by which the indigent may apply for assistance, specified the staff that will be responsible for processing requests for assistance. and detailed who is eligible. In addition, UHC of South West Georgia has notified in writing many of the community agencies who advocate for the Page 1 indigent of its intent to make services available to the indigent. The following are examples of steps being taken corporately within the United Home Care family of home health agencies: o The company web site, www.uhs-pruitt.com. has been updated to include an entire page on the availability of indigent care. Instructions regarding application and contact information are included. A "Screen Print" of the new web page, http://www.uhs- PI1.Iitt.tol11/Default.aspx?tabid=88, Was provided ill AttachIllent F to the Additional Infonnation. This web site lists all United Home Care agencies and will include the proposed agency should it receive the Departments' award. o UHC has also developed an informational brochure which will be distributed to hospitals, physicians, DFCS offices, Public Health offices, and other social service agencies providing assistance to those with limited means. The brochures will be available in all United Home Care home health offices as well as all UHS-Pruitt affiliated companies. Should the applicant be awarded a Certificate of Need, brochures will be mailed to all referral sources in the region. United Home Care Community Liaison staff will personally distribute this information to all of the region's hospitals who are the most likely to have inquiries regarding charitable home care services. o UHC has expanded the role of its medical social work staff to include financial counseling to any patient or referred individual who reports needing financial assistance. An orientation program for employed staff and contract staff is being developed and is anticipated to be deployed during the first quarter of calendar year 2007. o UHC is in the process of updating its orientation and continuing education program. The new components of the program clearly describe the companies commitment to providing indigent and charitable care and make clear to all employees how to refer inquiries to social work services for financial assistance and counseling. Rule 11l-2-2-.09(e): Rule 111-2-2-.32(m): Effects on Po:yors Comparable Charges Amedisys' application is inferior with regard to the effect on payors and comparable charges. Amedisys does not provide sufficient information to compare charges by discipline. For those payors who pay on the basis of visits, Amedisys projects comparatively high visits per patient and thus payors will be charged more by Amedisys than by UHC of South West Georgia. UHC of South West Georgia's projected charges are reasonable and within the range of existing charges for SSDR 8. Consistent with Governor Perdue's initiatives announced last fall, UHC of South West Georgia will ensure pricing transparency by providing pricing information and quality benchIllarking data through public sources such as the internet, local newspapers, public agencies, and to referral sources. UHe employs the services of UniHealth Select to interface with all private payors. UniHealth has negotiated standard rates with commercial payors for all of United Home Care's agencies. UHC of South West Georgia will be incorporated into this structure. UHC is also committed to utilizing information technology platforms that allow for the sharing of information required to implement these transparency initiatives. Page 2 Rule 111-2-2-.09(h): Positive Relationship with Healthcare Delivery System Amedisys does not meet the unmet need identified by the Department to the same extent as UHC of South West Georgia and therefore on a comparative basis does not have a positive impact on the healthcare delivery system. Futhermore, Amedisys provides little evidence of existing relationships or proposed community linkages within SSDR 8. Given that Amedisys is an existing provider within SSDR 8, it would appear that very little effort was made to obtain support for the proposed project. There are very few letters of support provided in Amedisys' application. By contrast, UHC of South West Georgia provides documentation of significant support from organizations and individuals within SSDR 8. Additionally, UHC of South West Georgia's affiliated organizations will work with it to develop an integrated service delivery model capable of sharing information and coordinating services. UHe's affiliated SOURCE program, which works with many providers of all levels of care and with a number of medical professionals, has agreed to incorporate UHC into its existing network and assist UHC in developing relationships with other existing members of the health care community in SSDR 8. Rule 111-2-2-.09(1): Rule 111-2-2-.32(3)(h): Clinical Needs of Health Professionals Ability to Recruit and Retain Qualified Staff Amedisys does not indicate that it has or plans to have any relationship with local clinical health training programs despite its presence as an existing agency in SSDR 8. Furthermore, Amedisys does not demonstrate that it will have relationships in place to recruit required clinical staff or address the health manpower shortages in SSDR 8. By contrast, UHC of South West Georgia will work closely with Georgia Southwestern State University to offer local preceptorship programs and, should it receive the Certificate of Need award, will offer a $15,000 scholarship for students in clinical training programs. UHC, through its parent and affiliated organizations, has extensive corporate training programs, numerous scholarships and grant programs, cross organizational advancement opportunities, and employee assistance programs in place that will encourage the retention of qualified staff. UHC of South West Georgia has also committed to work closely with the regional Area Health Education Center (AHEC) to address health manpower shortages through its community-based initiatives. On a comparative basis, UHC of South West Georgia best meets both the general and service specific review considerations and should be given favorable consideration in the review of the competing applications in SSDR 8. Page 3 , ~~ GaOa.IA Dm"'.'NT 0' tti~:,. 0>1;,,,,,11)....... /d," COMMUNITY HltALTa i;~' Y Georgia Certificate of Need Opposition to Project under Review ~ m I...----v---- @'>ENTER the Project Number and County below DATE STAMP for the project that you are opposing. Use the Format YYYY-###. PROJECT NUMBER GA 2006 - 131 COUNTY: Sumter Signed Origlnai and 3 Copies (T/I/$ Box for Dlvlstan of Health Planning Use Only) Applicant Name: F. C. of Georgia, Inc. d/b/a Intrepid USA HealthCare Services (Intrepid USA) Opposing Party Name: United Home Care of South West Georgia Inc. General Information: 1. This Opposition form Is a required document that must be submitted by a party wishing to oppose a project currently under consideration by the Department. Anyone may oppose a project, but only certain parties have standing to appeal a project that has been opposed. 2. Please review this form before attempting to complete and submit the information requested. 3. This form must be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 4. All form fields must be completed. If a field is not applicable, so indicate. 5. Attach your detailed opposition to this form. 6. This form and any and all attached sheets detailing reasons for opposition to the project under consideration must be submitted to the Department by the appropriate opposition deadline. · Opposition addressing Information contained In the application as origlnalll submitted by the Applicant must be submitted to the Department no later than the 60 day of the application review cycle; · Opposition addressing Information contained In additional Information submitted by the applicant prior to the 75th day of the review cycle must be submitted to the Department no later than the 83rd day of the review cycle; State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 1 · Opposition addressing information contained in an amendment to the project must be submitted to the Department no later than the 85th day, except when the review cycle of the project is extended to 120 days, such opposition must be submitted to the Department no later than the 115th day of the review cycle; · Notwithstanding the timeframes above, opposition to balched applications for home health and nursing facilities, regardless of whether such opposition Is to information contained in the original application, an amendment, or additional Information, must be submitted to the Department by the 85th day of the review cycle; and · Notwithstanding the timeframes above, opposition to expedited applications, regardless of whether such opposition is to Information contained in the original application, an amendment, or additional information, must be submitted to the Department by the 35th day of the review cycle. 7. Any opposition that is not submitted in a timely fashion as described in the previous paragraph will be returned and will not become part of the master file. 8. You must submit a signed original and three copies of this form and any and all attached documentation. 9. The signed original Opposition form and the three copies must be submitted on loose leaf, one-sided 8 Y.I by 11-inch paper only. Each copy and the original should be rubber banded to separate each copy and the original. · The signed original must not be hole punched nor stapled or otherwise bound. · The three copies must be three-hole-punched but must not be stapled or otherwise bound. 10. Faxed copies of documents and information are not official and must be followed-up with the original documents by the mandated deadline for Inclusion in a project master file. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 200S Page 2 OPPOSITION 1. Identify the opposing party. OPPOSING PARTY Legal Name: Un~ed Home Care of South West Georgia Inc. d/b/a (if applicable): Address; 3945 Lawrenceville Highway City: Lilbum I State: GA I Zip; 30047 2. Identify the authorized representative submitting this opposition. AUTHORIZED REPRESENTATIVE Name: I Title or Pos~ion: Address: City: I State: I Zip: Phone: I Fax: E-mail Address: 3. Does the oppOSing party have legal standing to appeal the application should it be approved? IZI Yes 0 No If YES + Complete the following table indicating the OpPOSing Party's purported standing. If NO + Continue to the next Question. You may still submit this oppos~ion. Is the Opposing Party a competing applicant? Is the Opposing Party a county or municipal government within whose boundaries the project will be located? Is the Opposing Party a competing health care facility? Is the Opposing Party notifying the Department of its opposition during the required time periOdS? Will the Opposing Party be aggrieved if the Department were to approve the application? IZI Yes 0 No DYes IZI No DYes IZI No IZI Yes 0 No IZI Yes 0 No State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 3 4. identify the Applicant for the project that you are opposing. APPLICANT INFORMATiON Applicant Legal Name: F. C of Georgia, Inc. d/b/a (if applicable): Intrepid USA Healthcare Services (Intrepid USA) Address: 6600 Frances Avenue South, Suite 510 City: Edine State: MN I Zip: 55435 County: Hennepin Project Number: 2006.131 Title of Applicant's Project: Development of a New Home Health Agency in SSDR 8 5. Indicate the ioeatlon of the information being opposed. Check onlv one of the following: IZIlnformation contained in the original submissIon of the Applicant (Verify that you are submitting your opposition by the 6d" day of the review cycle) o Information contained in additional information submitted by the Applicant (Verify that you are submitting your opposition by the 8~ day of the review cycle) o Information contained in an amendment (Verify that you are submitting your opposition by the f351' day of the review cycle) o Information submitted in the original submission, additional information, or an amendment to a batched home health or nursing facility application. (Verify that you are submitting your opposition by the f351' day of the review cycle) o Information submitted in the original submission, additional information, or an amendment to an expedited application. (Verify that you are submitting your opposition by the :;Sh day of the review cycle) 6. Attach 8-1/2 by 11-inch sheets of paper providing the specific reasons for the opposition to the Applicant's project. Please see the attached. 7. Does the Opposing Party have any iobbyist empioyed, retained, or affiliated with the Opposing Party directly or through its authorized representative? IZI YES 0 NO If YES -+ Please complete the information in the table on the next page for each lobbyist employed, retained. or affiliated with the Opposing Party. 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 -+ Continue to the next question. Slate of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 4 LOBBYIST DISCLOSURE STATEMENT Registered Name of LobbyIst Affiliation with. with State , Opposing Party Ethics Commission? Joe Tanner o Empioyed IZI Ves IZI Other Affiliation DNo Bill Roper o Employed IZI Ves IZI Other Affiliation DNo o Employed DVes o Other Affiliation DNo o Employed DVes o Other Affiliation DNo o Employed DYes o Other Affiliation DNo o Employed DVes o Other Affiliation DNo o Employed DYes o Other Affiliation DNo o Employed DVes o Other Affiliation DNo 8. Opposing Party Certification. By signing below, I hereby certify that the contained statements and all attachments hereto are true and cOmplete to the best of my knowledge and belief and that I possess the authority to submit this form and bind the OPPosing Party to promises made herein. Signature.~~ Igna Name: Neil L. Pruitt, Jr. Title: Chairman & CEO APPLiCANT CERTIFICATION UE I,XNL V): 01 Submit to: Division of Health Planning Department of Community Heaith 2 Peachtree Street, NW - S'" Fioor Atlanta, GA 30303 State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 5. United Home Care of South West Georgia Inc. F.C. of Georgia, Inc. d/b/a! Intrepid USA HealthCare Services (Intrepid USA) Project # 2006-131 United Home eare of South West Georgia, Inc. (UHC of South West Georgia) is a competing applicant through its CON application Project #2006-132. UHC of South West Georgia opposes the application filed by F.C. of Georgia, Inc. d/b/a! Intrepid USA Healtheare Services (Intrepid). Furthermore, UHC of South West Georgia asserts that it is the better applicant to meat the identified need for SSDR 8 for the following reasons: Rule 111-2-2-.06(2) Submittal of Applications Intrepid's application should not have been accepted as complete for review. Rule 111-2-2-.06(2) requires that the application be signed by a "legal representative of the applicant". Intrepid's application was signed by Newell D. Yarborough who is listed in Question 11, page 5 of the application. As the consultant, Mr. Yarborough is not a legal representative of the applicant. Furthermore, Mr. Yarborough was not identified in Question 12, page 5 as a legally authorized representative of the applicant. Finally, Mr. Yarborough in his capacity as a consultant is not able to: · bind the applicant to the promises made herein (part a); · certify that the applicant will submit progress reports (part b); · bind the applicant to representation made in the application (part d); and · certify that the applicant will accept condition or conditions on the award of the Certificate of Need (part e). Because Intrepid's application was not signed by a legal representative of the applicant, the application should have resulted in non-acceptance and been returned to the applicant as further stated in Rule 111- 2-2-.06(2). As such, the application was not complete for review and should not be considered as part of the joined applications to meet the unmet need in SSDR 8 published on September 14, 2006. Rule 111-2-2-.09(1)(a): Consistency with the State Health Plan Intrepid fails to meet this general review consideration because it does not adequately address certain other general and service specific rules. Only UHe of South West Georgia proposes to incorporate the proposed agency into an integrated continuum of long term care services which will enhance access and transparency, and promote the deliver of care and services at the most appropriate and cost-effective level of care. UHe of South West Georgia and its parent and affiliates bring vast resources and a vision for how home health services should be provided as part of the larger health system focused on continuously improving quality of care, cost effectiveness of services provided at the appropriate level, and enhancing accessibility of services. This vision, as outlined in this application, is consistent with the goals of the State Health Plan, Governor Perdue's recently stated initiatives related to transparency and choice, and recent CMS initiatives. Only UHC of South West Georgia has fully integrated the Governor's initiatives into its plans. Indeed, it has committed to expand its commitments to access and transparency in cost and quality to its existing agencies as well as the proposed agency. For this reason, UHC of South West Georgia's project better meets the criteria than the other joined applicants. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 6 Rule 11J.2-2-.09(1)(b): Rule 11J.2-2-.32( 3)(b): Needfor the Proposed Project Need for a New or Expanded Home Health Agency UHC of South West Georgia better meets the need identified in SSDR 8 and should be approved. By contrast, Intrepid fails to document and describe in detail its various proposed service offerings, specific disease management tools, or specific corporate programs and services that it will bring to the counties it proposes to serve. Intrepid will not offer home health services in SSDR 8 as part of an integrated continuum of long term care services such as UHe of South West Georgia proposes. Most importantly, Intrepid fails to provide any documentation of efforts made to date or plans to develop community linkages within SSDR 8. Only a handful of letters of support were provided. UHe of South West Georgia, by contrast, has significant documentation of efforts made to develop new relationships and extensive community support within SSDR 8 for its project. For this reason, UHC of South West Georgia better meets the identified unmet need in SSDR 8. Rule 11J.2-2-.09( 1)( d): Financial Feasibility Intrepid proposes to develop a headquarter office as a new home health agency. However, there are insufficient funds presented in the project costs to develop a new office. Such items as office furnishing and equipment, minor medical equipment, voice and data communications, wiring, and computer technology have not been included in its project costs. As a result, start-up and capital costs cannot be verified and assurances of adequate funding cannot be reliably made. Only UHC of South West Georgia fully discloses all costs associated with the development of a branch office to consider all office furnishings, office and medical equipment, wiring, telecommunication and computer systems. UHC of South West Georgia fully discloses the costs of its technology initiatives, including the hardware, software, and training costs associated with an electronic Point of Service (POS) program. Rule 111-2-2-.09(1)(g): Rule 111-2-2-.32(1): Financial Accessibility Financial Accessibility Intrepid does not project any self pay charges for the agency in the second year of operation, yet Intrepid proposes to write off $61,944 in indigent/charity care. Intrepid has not indicated how it will meet its commitment to indigent/charity care operationally and has not provided for any non-clinical or clinical staff to assist in these efforts. UHC of South West Georgia has provided a detailed plan which includes internet posting of its policies, a specific procedure by which the indigent may apply for assistance, specified the staff that will be responsible for processing requests for assistance, and detailed who is eligible. In addition, UHC of South West Georgia has notified in writing many of the community agencies who advocate for the indigent of its intent to make services available to the indigent. The following are examples of steps being taken corporately within the United Home eare family of home health agencies: State of Georgia: Certificate of Need OpposItion Form CON 105 Revised May 2006 Page 7 o The company web site, www.uhs-pruitt.com. has been updated to include an entire page on the availability of indigent care. Instructions regarding application and contact information are included. A "Screen Print" of the new web page, http://www.uhs- pruitt.com/Default.aspx?tabid=88, was provided in Attachment F to UHC of South West Georgia's Additional Information submission. This web site lists all United Home eare agencies and will include the proposed agency should it receive the Departments' award. o UHC has also developed an informational brochure which will be distributed to hospitals, physicians, DFeS offices, Public Health offices, and other social service agencies providing assistance to those with limited means. The brochures will be available in all United Home Care home health offices as well as all UHS-Pruitt affiliated companies. Should the applicant be awarded a Certificate of Need, brochures will be mailed to all referral sources in the region. United Home Care eommunity Liaison staff will personally distribute this information to all of the region's hospitals who are the most likely to have inquiries regarding charitable home care services. o UHC has expanded the role of its medical social work staff to include financial counseling to any patient or referred individual who reports needing financial assistance. An orientation program for employed staff and contract staff is being developed and is anticipated to be deployed during the fIrst quarter of calendar year 2007. o UHC is in the process of updating its orientation and continuing education program. The new components of the program clearly describe the companies commitment to providing indigent and charitable care and make clear to all employees how to refer inquiries to social work services for financial assistance and counseling. By contrast, Intrepid provides little evidence of its ability or intent to operationalize programs that will ensure that home health services are provided within SSDR 8 to patients without ability to pay for services including indigent and charity care patients. Rule 111-2-2-.09(e): Rule 111-2-2-.32(m): Effects on Payors Comparable Charges Intrepid's application is inferior with regard to the effect on payors and comparable charges. Intrepid's projected charges per visit by discipline are higher than those proposed by UHC of South West Georgia. UHC of South West Georgia's projected charges are reasonable and within the range of existing charges for SSDR 8. Consistent with Governor Perdue's initiatives announced last fall, UHC of South West Georgia will ensure pricing transparency by providing pricing information and quality benchmarking data through public sources such as the internet, local newspapers, public agencies, and to referral sources. UHC employs the services of UniHealth Select to interface with all private payors. UniHealth has negotiated standard rates with commercial payors for all of United Home Care's agencies. UHe of South West Georgia will be incorporated into this structure. UHe is also committed to utilizing information technology platforms that allow for the sharing of information required to implement these transparency initiatives. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 8 Rule 111-2-2-.09(h): Positive Relationship with Healthcare Delivery System Intrepid provides little evidence of existing relationships or proposed community linkages within SSDR 8. By contrast, UHC of South West Georgia provides documentation of significant support from organizations and individuals within SSDR 8. Additionally, UHe of South West Georgia's affiliated organizations will work with it to develop an integrated service delivery model capable of sharing information and coordinating services. UHC's affiliated SOURCE program, which works with many providers of all levels of care and with a number of medical professionals, has agreed to incorporate UHC into its existing network and assist UHe in developing relationships with other existing members of the health care community in SSDR 8. Rule 111-2-2-.09(/): Rule 111-2-2-.32(3)(h): Clinical Needs of Health Professionals Ability to Recruit and Retain Qualified Staff Intrepid does not indicate that it has or plans to have any relationship with local clinical health training programs. Furthermore, Intrepid does not demonstrate that it will have relationships in place to recruit required clinical staff or address the health manpower shortages in SSDR 8. By contrast, UHe of South West Georgia will work closely with Georgia Southwestern State University to offer local preceptorship programs and, should it receive the Certificate of Need award, will offer a $15,000 scholarship for students in clinical training programs. UHe, through its parent and affiliated organizations, has extensive corporate training programs, numerous scholarship and grant programs, cross-organizational advancement opportunities, and employee assistance programs in place that will encourage the retention of qualified staff. UHC of South West Georgia has also committed to work closely with the regional Area Health Education Center (AHEe) to address health manpower shortages through its community-based initiatives. On a comparative basis, UHe of South West Georgia best meets both the general and service specific review considerations and should be given favorable consideration in the review of the competing applications in SSDR 8. State of Georgia: Certificate of Need Opposition Form CON 105 Revised May 2006 Page 9 State Health Planning Review Board 2 Peachtree Street, N.W. 5th Floor Atlanta, Georgia 30303 INRE: AMEDISYS GEORGIA, LLC D/B/A ) PROJECT NO. GA 2006-130 AMEDISYS HOME HEALTH OF MACON ) ) INTREPID USA HEALTHCARE SERVICES, INC. ) PROJECT NO. GA 2006-131 ) UNITED HOME CARE OF SOUTHWEST GEORGIA, INC. ) PRO.TECT NO. GA 2006-132 APPOINTMENT OF HEARING OFFICER Sabrina Scott, Esq, is hereby appointed the Hearing Officer in the above-referenced case. This 3rd day of May, 2007. -f /':A J (j t'ntf.t'v+ C{. f-J~{L Lamont A. Belk, Esq. ~~/ Vice Chair v-' (-I- Health Planning Review Board CERTIFICATE OF SERVICE I hereby certify that I have this day served the foregoing APPOINTMENT OF HEARING OFFICER via first class mail as follows: Sidney R. Barrett, Jr., Esq. Senior Assistant Attorney Generaj Department of Law 40 Capitol Square Atlanta. GA 30334 Department of Community Health Division of Health Planning 2 Peachtree Street, NW, 5th Floor Atlanta, Georgia 30303-3159 Amedisys Home Health of Macon clo Stanley S. Jones, Jr., Esq. Nelson Mullins Riley & Scarborough, LLP 999 Peachtree Street, NE Suite 1400 Atlanta, Georgia 30309 United Home Care of North East Georgia clo Charies L. Gregory, Esq. Arnall Golden Gregory LLP 171 17th Street NW, Suite 2100 Atlanta, Georgia 30363-1031 This 3rd day of May, 2007. ~""* r;. ~el L . amont A. Belk, Esq. , .]~/ Vice-Chair LJv" ;<-, Health Planning Review Board Nelson Mullins Riley & Scarborough LLP Attorneys and Counselors at Law 999 Peachtree Street, NE / 14th Floor / Atlanta, GA 30309-3964 Tel: 404.817.6000 Fax: 404.817.6050 www.neIsonmullins.com Nelson Mullins TeI,4D4.8I7.6133 stan.jones@nelsonmuUins.com July 3, 2007 Sabrina Scott, Esq. Hearing Officer Department of Community Health 2 Peachtree Street, NW - 40th Floor Atlanta, GA 30303-3159 Department of Community Health Division of Health Planning 2 Peachtree Street, NW - 5th Floor Atlanta, GA 30303-3159 Re: Amedisys Georgia LLC djb j a Amedisys Home Health of Macon -- Proj. No. 2006-130 Intrepid USA Healthcare Services, Inc. - Proj. No. 2006-131 United Home Care of Southwest Ga" Inc. - Proi. No. 2006-132 Dear Ms. Scott: In response to your letter of June 25, 2007 regarding proposed dates of a hearing regarding the above-referenced matters, please note my availability choices as follows: Preferred Choice 1 Preferred Choice 2 Unavailable on October 2-5, 2007 August 20-24, 2007 September 18-2 1, 2007 Please advise as to your choice. Kind regards. Sincerely, ~/A7 /" , ,4 ." / ct,''''--_' x 'j. c '5t~ley ~. Jones, Jr. cc: DCH Office of General Counsel Robert Rozier, Esq. Atlanta. Boston. Charleston. Charlotte. Columbia. Greenville . Myrtle Beach. Raleigh. Washington, DC . Win<;ton-Salem Sabrina Scott, Esq. Hearing Officer Department of Community Health July 3, 2007 Page 2 cc: Continued Sidney R. Barrett, Jr., Esq. Sr. Assistant Attorney General Department of Law 40 Capitol Square, SW Atlant,a GA 30034-1300 United Home Care of North East Georgia c/o Charles 1. Gregory, Esq. Arnall Golden Gregory, LLP 171 17th Street, NW - Suite 2100 Atlanta, GA 30363-1031 Ked Conley, Esq. Nelson Mullins Riley & Scarborough, LLP 999 Peachtree Street Suite 1400 Atlanta, GA 30309 -Doc# 792062.1- hospital, while 14 percent came from a nursing home, and 38 percent from the community.2 Research has suggested that patients that are ~rovided care in a setting where continuity of dinical services exists have a lower risk of hospitalization. The importance of continuity of care stems from the idea that relationships with community agencies and other health care providers will streamline the home health referral process, and thus improve overall patient care and health. CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United included community linkage plans that detail ongoing and planned efforts to establish relationships with other entities in the service region. However, the level of detail and documentation of these plans varied among the applicants. Because of the competitive nature of the application process in SSDR 6, these community linkage plans and relationships are important factors in the analysis. CareSouth, Gentiva, Nightingale, Harmony and United induded various letters of support from area physicians, medical practices, nurses, pharmacies, governments, and other entities; TriStar did not offer any documentation of support in its application. The criteria of this role are minimally met by the applicants'proposed projects. Rule 111-2-2-.32(3)(e): An applicant for a new. or expanded home health agency shall provide a written statement of its intent to comply with all appropriate licensure requirements and operational procedures required by the Office of Regulatory SelVices of the Georgia Department of Human Resources. In order to ensure that citizens receive quality service, home health facilities offering services in Georgia are required to abide by minimum operational standards. The Office of Regulatory Services of the Georgia Department of Human Resources establishes these standards in their licensure rules and operational procedures. In their applications, CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United have stated their formal intent to comply with the appropriate licensure requirements and operational procedures. In addition, applicants with related entities that provide home health care have provided documentation from the Office of Regulatory Services stating that none of the agencies have any outstanding compliance issues or deficiencies. The criteria of this role are met by the applicants' proposed projects. Rule 111-2-2-.32(3){f); An applicant for a new or expanded home health agency or agency(ies) owned and/or operated by the applicant or its parent organization shall have no history of uncotTected or repeated conditional level violations or unconected standatd deficiencies as identified by licensure inspections orequivalent deficiencies as noted from Medicare or Medicaid audits. CareSouth, Gentiva, Nightingale. TriStar, and United have stated in their applications that there is no history of uncorrected or repeated conditional level violations or uncorrected standard deficiencies as identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. Furthermore. documentation from the Office of Regulatory Services included with these applicants' applications states that none of the home health applicants have any of these deficiencies. As a new entity. Harmony has no Ucensure history. 2 us Department of Health and Human Services, Office of Inspector General (2001). Access to Home Health C8Ie After HospltalDischarge 2001. 3 Mainous. AG, Gill, JM (1998). The importance of continuity of care in the Bkelihood of future hospitalization: is site of care equivalent to a primary clinlci8n? American Journal of Public Health, 88(10), 1539-41. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 7 The criteria of this rule are met by the applicants' proposed projects. Rule 111-2-2-.32(3J(a): An applicant for a new or expanded home health agency or agency(ies) owned and/or ope/Bted by the applicant or. its parent organization shall have no previous conviction of Medicaid or Medicare f/Bud. CareSouth, Gentiva, Nightingale, TriStar, and United have all stated in their applications that neither they nor their affiliated organizations have previously been convicted of Medicaid or Medicare fraud. As a new entity, Harmony has no Medicaid or Medicare history. The criteria of this rule are met by the applicants' proposed projects. Rule 111-2-2-.32(3)(h): An applicant for a new or expanded home health agency shall provide a written plan which demonstrates the intent andabHity to recruit. hire and ~tain the appropriate numbers of qualified personnel to meet the requirements of the services proposed to be provided and that such personnel are available in the proposed geographic selVice area. CareSouth testifies to the existence of its Human Resources department, Which will recruit the necessary staff through advertising; the organization also cOntinuously provides clinical training activities for its employees. Gentiva also will rely on its Human Resources Department to procure staff for the new agency, and will utilize advertisements, internet postings, and open houses; Gentiva includes a detailed recruitment strategy along with employment qualifications in its application. Nightingale states that it will utilize its existing recruitment methods, such as advertisements and job fair participation, and also provides educational opportunities for its staff. Harmony will employ traditional methods to procure staff, including advertisements, recruitment . through professional organizations, and transfer opportunities. TriStar testifies that it will hire staff through advertisements, recruiting conventions, career fairs, and intern programs. United states that it will utilize traditional recruitment methods, such as advertisements and internet postings, in addition to establish relationships with area educational programs. The chart below details the projected number of full-time equivalent home health employees the agencies will utilize by the second year of the implementation of the project. ~~~~~~5~~~~_;~ CareSouth Gentiva Nightingale Harmony TriStar United 10,556 20,991 12,588 22,448 - ._-" -.,--' n__.__... . .- - ,"... ~ ,- 8.14 17.1 10.7 13.67 Projected Visits 21,733 22,352 ..._.~._..,. uu.,_...__.......____.__.. ,. . .__. ._ __.... __ Clinical Employees 15.41 16.8 Source: CON sppflCaOOns GA2006-124.125, 126, 127, 128, 129 SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 8 According to the National Association for Home Care and Hospice (NAHCH), the average number of visits per eight hour day for total home health staff is 5.38. Applicants also provided their own justification as to determining their required staffing levels. CareSouth, Gentiva, Harmony, and United propose to hire the following number of clinical full time staff members to serve the need of 1,298 patients by the end of Year 2: CareSouth. 15.41 (augmented by additional employees when necessary); Gentiva, 16.8; Harmony, 17.1; and United, 13.67 (augmented by contract employees when necessary). Nightingale proposes to employ 8.14 clinical full time staff members to serve 613 patients, and TriStar proposes to hire 10.7 clinical full time staff members to serve 685 patients. CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United all suggest an amount of staff in line with what is necessary to provide the average number of visits per day reported by the NAHCH; the Department has determined that these numbers are an adequate amount to serve the proposed patient need. The criteria of this rule ala met by the applicants' proposed projects. Rule 111-2-2-.32(3)ffl: An applicant for a new home health agency shall provide evidence of the Intent to meet the appropriate accreditation requirements of the Joint Commission for Accreditation of Health Cala Organizations (JCAHO), the Community Health Accladitation Program, Inc. (CHAP), and/or other appropriate accrediting agencies. Accreditation by JCAHO, CHAP, or other appropriate agency indicates that the organization meets certain performance standards in providing quality patient care. . All of the applicants have stated their intent to meet the appropriate accreditation requirements of JCAHO. CareSouth, Gentiva, and United currently have related entities that participate in JCAHO accreditation processes. The home health agencies of CareSouth and Gentiva are both completely accredited, indicating full compliance with JCAHO standards. However, United is currently only conditionally accredited as a result of not being in full compliance with JCAHO standards. The criteria of this rule ala met by the CalaSouth's, Gentiva's, Nightingale's, Hamlony's, and TriStars proposed projects. The criteria of this rule ala not met by United's proposed project. Rule 111-2-2-.32(3J{j): An applicant for an expanded home health agency shall provide documentation that they ala fully accredited by the Joint Commission for Accreditation of Health Cala Otganizations (JCAHO), the Community Health Accreditation Program, Inc. (CHAP), and/or other appropriate accladiting agency. CareSouth, Gentiva, Nightingale, TriStar, and United have proposed to establish new home health agencies in SSDR 6. No existing home health agencies have proposed to expand services in this region. The criteria of this rule ala not applicable to the applicants' proposed projects. Rule 111-2-2-.32(3)(k): An applicant for a new or expanded home health agency shall provide its existing or proposed plan for a complahensive quality Improvement program. 4 National Association for Home Care and Hospice. Hospital and Healthcare Compensation Service (2003). Homecare Sal8IY and Benefits Report 2003-2004. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 9 The Home Health Services Component Plan dictates that home health agencies should have in place a quality program that addresses the areas of patient outcomes, consumer satisfaction, consumer demand, and patient/consumer rights. . CareSouth included explanation and documentation in its application that details the company's. participation in monitoring and improving performance activities, including the Care Coordination, Care Planning Process, and Improving Organizational Performance policies. CareSouth also utilizes Outcome Concept Systems and Outcome and Assessment Information Set (OASIS) to measure quality and provide benchmarks. . Gentiva submitted a copy of its HHA Quality Improvement Policies and Procedures, which describes goals and methods of ensuring and improving the quality of care a patient receives. This document also details the Utilization Review and Risk Management policies, which are integral components of a comprehensive quality improvement program. . Nightingale included copies of its Annual Agency Evaluation policy and its Quality Assurance Plan; these documents detail how the organization evaluates the quality of care that it provides to its patients. . Harmony provided a draft of its Quality Improvement Policy in its apPlication. This policy includes processes for operating a system that monitors, evaluates. and improves patient care quaflty. . TriStar submitted its Performance Improvement Plan. which provides direction for monitoring, analyzing, and improving the functions of the home health agency, resulting in the improved quality of patient care. . United provided a copy of its Performance Improvement Policy and Procedure Manual. This manual outlines procedures that the company implements for improving the quality of care provided to patients, including performance measurement. assessment, and improvement The criteria of this role ate met by the applicants' proposed projects. Rule 111-2-2-.32(3)0): An applicant for a new or expanded home health agency shall assure access to seNices to individuals unable to pay and to all individuals regardless of payment source or circumstances by: 1. providing evidence of written administrative policies that prohibit the exclusion of seNices to any patient on the basis of age, disability, gender, race, or ability to pay; 2. providing a written commitment that services for indigent and charity patients will be offered at a standard which meets or exceeds three percent of annual, adjusted gross revenues for the home health agency or, in the case of an applicant providing other health services, the applicant may tequest that the Division allow the commitment for seNices to indigent and charity patients to be applied to the entite facility~ 3. providing documentation of the demonstrated perfonnance of the applicant, and any facility in Georgia owned or operated by SSDR 6 Fall 2006 Home Health Batchlng March 13, 2001 Evaluation of Projects Page 10 the applicanfs parent organization, of providing seNices to Medicare, Medicaid, and indigent and charity patients; 4. providing a written commitment to participate in the Medicare, Medicaid and Peach Care programs; and 5. providing a written commitment to participate in any other state health benefits insurance programs for which the home health service is eligible. Rule 111-2-2-.09(1){q): The new institutional health seNice 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 CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United provided evidence in their applications of .the prohibition of exclusion of patients based on age, disability, gender, race, religion, or ability to pay, among other demographic characteristics. The applicants also included documentation detailing the provisions for supplying indigent and charity care. These policies are listed below. · CareSouth: Admission Criteria and Process, Uncompensated Care For Indigent and Charity Patients · Gentiva: Admission, Non-Discrimination (did not include copies of policies related specifically to the provision of indigent and charity care) · Nightingale: IndigentlCharity Assistance Policy (did not include copies of policies related to non- discriminatory practices) · Harmony: Admission Criteria, Non-Discrimination Policy, Uncompensated Care for Indigent Patients · TriStar: Admission Policy and Procedure/Criteria · United: Acceptance of Applicants for Home Health Care, United Home Care Patient Rights, Policy Regarding the Medically Indigent CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United made formal written commitments to provide a level of indigent and charity care that meets or exceeds 3 percent of the annual, adjusted gross revenue of the home health agency. In addition to this commitment, all applicants included detailed descriptions of their plans for providing actual medical care to indigent and charity patients, rather than paying the Department the difference between what was actually and what should have been provided. CareSouth, Gentiva, and United are the only applicants in SSDR 6 that currently provide home health services in other agencies around the state, and thus provide data annually to the Division of Health Planning. Their overall statewide historical indigent and charity care performance is detailed below in the chart. As Nightingale, Harmony, and TriStar are either new providers or do not provide CON-authorized home health services, their indigent and charity care performance is not ~ble to be analyzed. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 11 . . SSDR 6 Home Health Batching, Indigent & Charity Care Utilization 3% i 3% - .. CD ::J ::J 2% :a'c: c(CD - ~ 2% oQ: CD 411 ~411 1% 1:2 CDO ~ 1% :. 0% CareSouth Gentiw United . 2004 Before Shortfal Paid . 2004 After ShortfaR Paid . 2005 Before Shortfal Paid . 2005 After ShortfaU Paid Source: Division of Health Planning, 2004-05 Home Health Agency Surveys All applicants provided a written commitment in their applications to participate in the Medicare, Medicaid, Peach Care, and any other state health benefits insurance programs for which home health service is eligible. A commitment to participating in the Medicare and Medicaid programs is important, as Medicare is the largest payor for home health services; of the total amount of money spent on home health care in 2004, Medicare provided 38.01 percent of the payments, while Medicaid provided 17.46 percent 5 Again, CareSouth, Gentiva, and United are the only applicants in SSDR 6 that currently provide home health services in other agencies around the state, and their historical Medicaid and Medicare performance is detailed below in the chart. Nightingale, Harmony, and TriStar are not included in this chart, as no data from them has been submitted to the Division of Health Planning 5 US Department of Health and Human Services,. Centers for Medicare and Medicaid Services, The Office of the Actuary, National Health Statistics Group (2006). National Health Expenditures Data. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13,2007 Page 12 SSDR 6 Home Health Batching, Medicare & Medicaid Utilization 100% I 80% . ~ .. Q. ~ 60% ~ 40% & f 20% . e . Q. 0% 2004 Medicare 2004 Medicaid 2005 Medicare 2005 Medicaid \- CareSouth . Gentiva _ United I Souroe: DMsion of Health Planning, 2004-05 Home Health Agency SutVeys Based on known past perfonnance, non-discriminatory policies. plans for providing indigent and charity care, and written commitments for the provision of indigent and charity care, CareSouth, Gentiva, Nightingale, Hannony. TriStar, and United have all demonstrated to be physically and financially accessible to patients requiring home health care in SSDR 6. The criteria of this role are minimally met by the applicants' proposed projects. Rule 111-2-2-.32(3Um): An applicant for a new or expanded home health agency shall demonstrate that their proposed charges compare favorably with the charges of existing home health agencies in the same geographic service area. Under the Medicare prospective payment plan, home health agencies are paid a fixed. amount per patient visit, regardless of the actual charges. Medicaid patients are also paid for based on pre-set rates. These governmental payors account for the majority home health patients, and thus, projected charges are not applicable for much of the patients. However, all applicants did provide projected charges, which were similar to the charges of existing home health agencies in SSDR 6 that have been reported to the Division. The criteria of this role are met by the applicants' proposed projects. Rule 111-2-2-.32(3Un): An applicant for a new or expanded home health agency shall document an agreement to provide Division requested information and statistical data related to the operation and provision of home health services and to report that data to the Division in the time frame and format requested by the Division. SSDR 6 Fall 2006 Home Health Batching Evaluation ofProjecls March 13, 2007 Page 13 CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United have all agreed to provide to the Division the requested information and statistical data related to the provision and operation of their home health services, in the requested format and during the time period. Uniformly collecting this data allows for precise assessment of quality and patient outcomes, in addition to community benefits. and allows for the analysis of changing patterns and projected service. needs related to the provision of home health services. The criteria of this rule are met by the applicants' proposed projects. Rule 111-2-2-.32(3)(0): The deparlment may authorize an existing home health agency to transfer one county or several counties. to another existing home health agency without either agency being required to apply for a new or expanded certificate of need, provided the fo/lowing conditions are met: 1. the two agencies agree to the transfer and submit such agraement and a joint request to transfer in writing to the depa1fment at least thirty (3D) days prior to the proposed effective date of the transfer; 2. the two agencies document within the written request that the transfer would result in increased and improved setvices for the residents of the county or counties including Medicare and Medicaid patients; 3. the agency to which the county or counties are. being transferred currently offers setvices in at least one contiguous county or within the health planning area(s) in which county or counties are located; and 4. the two agencies are in compliance with all other requirements of these Rules; such compliance to be evaluated with the written transfer request No such transfer shall become effective without written approval from the depa1fment. None of the applicants in the current batching review cycle for SSDR 6 are proposing to transfer any counties between differing agencies. The criteria of this rule are not applicable to the applicants' proposed projects. General Review Considerations. cont'd. Rule 111-2-2-.09(1)(c}: 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 Depa1fment and is currently valid. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of projects March 13,2007 Page 14 According to the 2005 Annual Home Health Survey, 5 agencies provided services in SSDR 6. These agencies collectively served 6,094 patients, for a total of 104,944 visits in SSDR 6. Based on the need methodology outlined in Rule 111-2-2-.32(3), the Division of Health Planning identified a numerical unmet need for services in SSDR 6, despite the operations of these home health agencies. As United's project also did not meet the criteria of Rule 111-2-2-.32(3)(i), as detennined by the Department, viable alternatives to the project proposed by this applicant exist, in the fonn of the other applicants in SSDR 6. The criteria of this rule are minimally met by CareSouth's, Gentiva's, Nightingale's, Harmony's, and TriStar's proposed projects. The criteria of this rule are not met by United's proposed project Rule 111-2-2-.09(1)(dJ: The project can be adequately financed and is, in the intermediate and the long-term, financially feasible. . CareSouth estimates a total project cost of $55,500, which will be financed through unrestricted cash reserves on hand, as documented by Care80uth Homecare Professionals Chief Financial Officer John M. Southern. The applicant anticipates hiring 30.51 full time employees. By Year 2, CareSouth projects to serve all 1,298 patients in its proposed service area, with an average of 16.74 visits per patient during the year, and income is projected over expenses. The applicant estimates the expanded home health services to be offered by June 1. 2007. . Gentiva estimates a total project cost of $45.264, which WIll be financed .through unrestricted cash reserves on hand, as documented by Gentiva Home Health Executive Vice President and President Tony Strange. The applicant anticipates hiring 24.8 full time employees. By Year 2, Gentiva projects to serve all 1.298 patients in its proposed service area, with an average of 17.22 visits per patient during the year, and income is projected over expenses. The applicant estimates the expanded home health services to be offered by June 1. 2007. . Nightingale estimates a total project cost of $68,181. which will be financed through unrestricted cash reserves on hand, as documented by Nightingale Medicare Inc. Chief Executive Officer Harold C. Sims II. The applicant anticipates hiring 14.14 full time employees. By Year 2, Nightingale projects to serve all 613 patients in its proposed service area, with an average of 17.22 visits per patient during the year, and income is projected over expenses. The applicant estimates the expanded home health services to be offered by June 2007. . Hannony estimates a total project cost of $68,000, which will be financed through a commercial loan. as documented by SunMark Community Bank. The applicant anticipates hiring 27.1 full time employees. By Year 2. Hannony projects to serve a\l1 ,298 patients in its proposed service area, with an average of 16.17 visits per patient during the year, and income is projected over expenses. The applicant estimates the expanded home health services to be offered by September 2007. . TriStar estimates a total project cost of $80.500, which will be financed through unrestricted cash reserves on hand, as documented by TriStar Healthcare, Inc. Chief Financial Officer Gary W. Rasmussen. The applicant anticipates hiring 37.4 full time employees. By Year 2. TriStar projects to serve all 685 patients in its proposed service area, with an average of 18.37 visits per patient during the year, and income is projected over expenses. The applicant estimates the expanded home health services to be offered by December 1, 2007. SSDR6 Fall 2006 Home Health Batchlng Evaluation of Projects MliIrch 13, 2007 Page 15 " . United estimates a total project cost of $228,363, which will be financed through unrestricted cash reserves on hand, as documented by UHS-Pruitt Chief Financial Officer Greg Wren. The applicant anticipates hiring 23.91 full time employees. By Year 2, United projects to serve all 1,298 patients in its proposed service area, with an average of 17.29 visits per patient during the year, and income is projected over expenses. The applicant estimates the expanded home health services to be offered by June 15. 2007. The criteria of this rule are met by the applicants' proposed projects. The effects of the new institutional health service on payors for health services, including governmental payors, are not unreasonable. The Division has identified a need for expanded home health services in SSDR 6. As the Center for Medicaid and Medicare Services (CMS) has set regulations that only allow Medicare payments to be made on a fixed prospective payment system, Medicare patients of home health agencies are paid for per an episodic system, regardless of actual charges. Thus, the proposed home health expansion by CareSouth is not predicted to have any unreasonable effects on payors for health services. The Deparbnent has determined that the project proposed by United results in unreasonable effects on payors for health services. given that the applicant did not meet the criteria for Rule 111-2-2-.32(3)(Q, and Rule 111-2-2-.09(1)(c). Rule 111-2-2-.09(1 )(e): The criteria of this role are minimally met by CareSouth's, Gentiva's, Nightingale's, Hannony's, and TriStars proposed projects. The criteria of this rule are not met by United's proposed project. Rule 111-2-2-.09(1)tn: The costs and methods of a proposed construction project, including the cpsts and methods of energy provision and conservation, are reasonable and adequate for quality health care. As most home health services are administered in a patienfs place of residence, be that a private home or other residential living facility, little to no construction is necessary with home health expansion projects. CareSouth, Harmony, and TriStar propose to establish offices in Wamer Robins, Houston County, while Gentiva, Nightingale, and United propose to establish offices in Macon, Bibb County; however, no new construction is being proposed by the applicants. CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United have included in their application proof of legal entitlement to the sites of their proposed operational offices. Additionally. they have stated that these locations are appropriately zoned for the provision of administrative functions of home health services. The criteria of this role are met by the applicants' proposed projects. Rule 111-2-2-.09(1 )(h): The proposed new institutional health service has a positive relationship to the existing health care delivery system in the service area. CareSouth, Gentiva, Nightingale, Harmony, and TriStar. through their community linkage plans, historical provisions for providing care to Medicaid, Medicare, indigent, and charity patients (applicable only to CareSouth and Gentiva), in addition to their plans for meeting their future commitment to provide three percent of annual gross adjusted revenue in indigent and charity care, have shown that hey will have a positive relationship to the existing healthcare delivery system. SSDR 6 Fan 2006 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 16 As a result of United not meeting the criteria set by Rule 111-2-2-.32(3)(i), Rule 111-2-2-.09(1)(c), and Rule 111-2-2-.09(1)(e), the Department has determined that its proposed project will not have a positive relationship to the existing healthcare delivery system. The criteria of this rule am minimally met by CareSouth's, Gentiva's, Nightingale's, Harmony's, and Tristar's proposed projects. The criteria of this rule am not met by United's proposed project. Rule 111-2-2-.09(1)(i); The proposed new institutional health service encourages more efficient utilization of the health cam facility proposing such service. CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United are not existing home health providers in SSDR 6. The criteria of this rule are not applicable to the applicants' proposed projects. Rule 111-2-2-.09(1)(j); The proposed new institutional health service provides, or would provide, a substantial porlion of its services to individuals not residing in its defined service ama or the adjacent service area. CareSouth, Gentiva, Nightingale. Harmony, TriStar, and United are not proposing to provide a substantial portion of home health services to individuals residing outside its defined service area. The criteria of this rule are not applicable to the applicants' proposed projects. Rule 111-2-2-.09(1)(k); 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. CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United are not proposing to conduct biomedical or behavioral research studies or develop a new service with their proposals to establish of a new home health agency in SSDR 6. The criteria of this rule am not applicable to the applicants' proposed projects. Rule 111-2-2-.09(1){/); The proposed new institutional health service meets the clinical needs of health professional programs which request assistance. CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United all stated in their applications that upon the establishment of their proposed home health agencies, they will participate in programs that meet the clinical needs of health professional programs, including training. partnership, and scholarship activities. The criteria of this rule are met by the applicants' proposed projects. Rule 111-2-2-.09(1)(m); 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 SSDR 6 Fall 2006 Home Health Batchlng Evaluation of projects March 13, 2007 Page 17 fosters competition that is shown to msult in lower patient costs without a loss in the quality of care. CareSouth, Gentiva, Nightingale, Harmony, and TriStar have provided sufficient evidence that the proposed establishment of a new home health agency will foster improvements in the delivery of care in SSDR 6. Their detailed community linkage plans . and documentation of working agreements and referral arrangements indicates that the applicants that will be able to effectively selVe patients in the area that require home health services. Additionally, among those applicants with applicable history, they have no deficiencies in accreditation, and have historically provided indigent and charity care to patients. The Department has determined that United's proposal would not foster improvements in the delivery of health services, as the criteria of criteria set by Rule 111-2-2-.32(3)(i), Rule 111-2-2-.09(1)(c), Rule 111-2-2-.09(1)(e) and Rule 111-2-2-.09(1)(h) have not been met. The criteria of this role are minimally met by CareSouth's, Gentiva's, Nightingale's, Hannony's, and TriStar's proposed projects. The criteria of this rule are not met by United's proposed project. Rule 111-2-2-.09f1Un}: The proposed new institutional heaUh service fosters the . special needs and circumstances of health maintenance oTgBnizations. As CareSouth, Gentiva, Nightingale, Harmony, TriStar, and United are not health maintenance organizations, the proposed establishment of new home health agencies. in SSDR 6 is not being proposed to foster the special needs and circumstances of these particular organizations. The criteria of this role are not applicable to the applicants' proposed projects. Altemative Review Addendum As CareSouth, Gentiva, Nightingale, Harmony, and TriStar have all minimally met the standards described In the previously cited rules, the following tie-breaker criteria are necessary in order to further distinguish between the applicants. United is not included in the following analysis, as this applicant has already been disqualified based on evaluation of Rule 111-2-2-.32(3)(i), Rule 111-2-2-.09(1)(c), Rule 111-2-2-.09(1)(e), Rule 111-2-2-.09(1)(h), and Rule 111-2-2-.09(1)(m). Rule 111-2-2-.08f1Uh): In evaluating batched applications, if any or all of the batched applications equally meet the statutory considerations, priority consideration will be given to a comparison of the applications with regard to: 1. The past and present records of the facility, and other existing facilities in Georgia, if any, owned by the same pamnt organization, regarding the provision of service to all segments of the papulation, particularly including Medicare, Medicaid, minority patients and those patients with limited or no ability to pay; Nightingale, Harmony, and TriStar do not have any record (past or present) regarding the provision of home health services to all segments of the population, and thus, cannot be analyzed or compared to CareSouth or Gentiva. CareSouth and Gentiva have both met previous indigent and charity care commitments made by their affiliated agencies; however, based on information provided to the Division, Gentiva has provided a greater percentage of indigent and charity care of the past 2 years. CareSouth SSDR 6 Fall 2006 Home Health Batchlng Evaluation of projects March 13, 2007 Page 18 " has served a larger proportion of Medicare patients during the period from 2004 through 2005; it has also served a larger proportion of Medicaid patients when compared to Gentiva. Applying the criteria of this tie-breaker role, CareSouth's project is given the advantage. 2. Specific services to be offered; CareSouth, Gentiva, Nightingale, Harmony, and TriStar all propose to offer home health services in SSDR 6. Applying the criteria of this tie-breaker role, no project is given an advantage. 3. Appropriateness of the site, i.e., the accessibility to the population to be served, availability of utilities, transportation systems, adequacy of size, cost of acquisition, and cost to develop; As home health is primarily provided in a patienfs home, the appropriateness of the site of the project is not as important as it is in planning for the. provision of other medical services. However, CareSouth, Gentiva, Nightingale, Harmony, and TriStar all proposed locations for their branch offices that are central to their proposed service areas. Applying the criteria of this tie-breaker role, no project is given an advantage. 4. Demonstrated readiness to implement the project, including commitment of financing; CareSouth's application contained a much greater amount of documentation of referral agreements, working arrangements, and general support for the project than compared to the other applicants. This substantial documentation, along with its detailed descriptions of its community linkages, indicates that CareSouth is the applicant with the greatest ability to target patients in need of home health seJVices, while ensuring continuity of care among various providers for these home health patients. The Department has determined that CareSouth presented substantiating evidence of its community relationships, working arrangements, and referral agreements in its proposed service area, through its description of its various programs and letters of support. CareSouth's application included evidence of its ability to create and maintain relationships in its proposed service area in a timely fashion, while Gentiva's, Nightingale's, Harmony's, TriStar's, and United's applications did not offer evidence of community linkages in the detailed manner provided by CareSouth. Applying the criteria of this tie-breaker role, CareSouth's project is given the advantage. 5. Patterns of past performance, if any, of the applicants in implementing previously approved projects in a timely fashion; Nightingale, Harmony, and TriStar do not have any past record regarding the implementation of projects in a timely fashion, and thus, cannot be analyzed or compared to CareSouth or Gentiva. CareSouth and Gentiva do not have any issues (besides those related to appeals of decisions) regarding timely implementation of projects. SSDR 6 Fall 2006 Home Health Batchlng evaluation of Projects March 13, 2007 Page 19 " Applying the criteria of this tie-breaker rule, no project is given an advantage. 6. Past record, if any, of the applicant facility, and other existing facilities owned by the same parent organization, if any, in meeting licensure requirements and factors relevant to providing accessible, quality health care; Hannony does not have any past record regarding licensure requirements, and thus, cannot be analyzed or compared to CareSouth, Gentiva, Nightingale, and TriStar. CareSouth, Gentiva, Nightingale, and TriStar do not have any issues regarding meeting licensure requirements. Applying the criteria of this tie-breaker rule, no project is given an advantage. 7. Evidence of attention to factors of cost containment, which do not diminish the quality of care or safety of the patient, but which demonstrate sincere efforls to avoid significant costs unrelated to patient care; and; Excessive costs are not a factor in any of the proposals submitted by CareSouth, Gentiva, Nightingale, Hannony, and TriStar. The pro fonna breakdowns list costs related only to the provision of home health care in SSDR 6. Applying the criteria of this tie-breaker rule, no project Is given an advantage. 8. Past compliance, if any, with survey- and post-approval repotfing requirements and Indigent and charity care commitments. Nightingale, Hannony, and TriStar do not have any past record regarding surveys, post-approval reporting, and indigent and charity care commitments, and thus, cannot be analyzed or compared to CareSouth or Gentiva. CareSouth and Gentiva do not have any issues regarding these requirements. Applying the criteria of this tie-breaker rule, no project is given an advantage. Applying the criteria of the individual components of this tie-breaker rule, CareSouth's project is given the advantage. General Review Considerations. confd. Rule 111-2-2-.09(1)(a): The proposed new institutional health services are reasonably consistent with the relevant general goals and objectives of the State Health Plan. The Home Health Services Component Plan states the following goal: "to ensure that Georgia citizens have access to cost-effective, efficient, and quality home health services." By meeting all the criteria of the rules described in the General Review Considerations and the Home Health Addendum, CareSouth's proposed expansion of services has been found to be consistent with the goals and objectives of the State Health Plan. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13,2007 Page 20 " The proposed home health establishment of services submitted by United has been determined to be inconsistent with the relevant general goals and objectives of the State Health Plan, under the following rules: · Rule 111-2-2-.32(3)(i) · Rule 111-2-2-.09(1)(c) · Rule 111-2-2-.09(1)(e) . Rule 111-2-2-.09(1)(h) · Rule 111-2-2-.09(1)(m) · Rule 111-2-2-.08(1)(h) Additionally. Gentiva, Nightingale, Harmony, and TriStar have been determined to be inconsistent under the following rule: . Rule 111-2-2-.08(1)(h) CareSouth meets the criteria of this rule. Gentiva, Nightingale, Harmony, TriStar, and United do not meet the criteria of this rule. SSDR 6 Fall 2006 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 21 " CONCLUSION CareSouth HHA Holdings of Columbus, LLC d/b/a CareSouth Homecare Professionals, Gentiva Health Services of Central Georgia, Inc., Nightingale Medicare, Inc. dIb/a Nightingale, Premier Home Health Care, LLC dIb/a Harmony Home Health of Middle Georgia, SunCrest Healthcare, Inc. dIb/a TriStar Home Health, and United Home Care of Middle Georgia, Inc. have each requested a Certificate of Need to establish new home health services in SSDR 6. Based on the evaluation findings of the Certificate of Need Rules relevant to the proposed project, it is the decision of the Georgia Department of Community Health, Division of Health Planning to ISSUE a Certificate of Need to CareSouth HHA Holdings of Columbus, LLC d/b/a CareSouth Homecare Professionals, to establish home health services in SSDR 6. Furthermore, it is the decision of the Georgia Department of Community Health, Division of Health Planning to DENY a Certificate of Need to Gentiva Health Services of Central Georgia, Inc., Nightingale Medicare, Inc. d/b/a Nightingale, Premier Home Health Care, LLC d/b/a Harmony Home Health of Middle Georgia, SunCrest Healthcare, Inc. d/b/a TriStar Home Health, and United Home Care of Middle Georgia, Inc. Additionally, the certifICate is valid for a period of twelve (12) months, unless extended for good cause. It is important that the administration of your project be consistent with the Certificate of Need roles. Accordingly, a copy of "Post Approval Requirements, II which outlines the duration, progression, and extension provisions (if needed) that apply to this approval is available at the Department's website: www.dch.aeoraia.aov. Please be advised that a decision by the Department is subject to appeal within thirty (30) days from the date it is rendered. Should a bona fide request for an appeal be received, you will be promptly notified and the Certificate of Need will be suspended until the appeal is resolved. You are strongly advised not to make a substantial obligation of funds until the time period for requesting an appeal has expired. The approval of a project by the Department of Community Health, Office of General Counsel does not assure that any amount or rate of reimbursement will be paid by the Division of Medical Assistance, the Medicare intermediary, or any other payment source. SSDR 6 FaR 2006 Home Health Batchlng Evaluation of projects March 13,2007 Page 22 . .' ~ , DEPARTMENT OF COMMUNITY HEALTH OFFICE OF GENERAL COUNSEL Evaluation for Certificate of Need Home Health Batchlng Cycle State Service Delivery Region 12 2006-133 Amedisys Georgia, LLC d/b/a Amedisys Home Health of Brunswick 2006-134 Gentiva Certified Healthcare Corporation d/b/a Gentiva Health Services - Savannah 2006-135 Island Health Care, Ine d/b/a Island Health Care 2006-136 Island Health Care, Inc. d/b/a Island Health Care 2006-137 Premier Home Health Care, LLC d/b/a Hannony Home Health of Coastal Georgia 2006-138 United Home Care of Coa~tal Georgia, Inc BACKGROUND Home health services enable health care, medical care, social support services and other therapies to be delivered to individuals In their place of residence Rule 111-2-2-.32(2}(a) defines a home health agency as a public agency or private organization, or a subdivision of such an agency or organization, which is primarily engaged In providing care to individuals who are under a written plan of care of a physician, on a visiting basis in the place of residence used as such Individual's home,part-tlme or intennlttent nursing care provided by or under the supervision of a registered professional nurse, and one or more of the following services: physical therapy. occupational therapy, speech therapy, medical-soclal services under the direction of a physician, or part-tIme or Intermittent services of a home health aide. PROJECT OVERVIEW On September 14, 2006, the Department of Community Health, Division of Health Planning published a Batchlng Review Cycle Notification for Home Health Services. This notification outlined the numerical need for home health services in applicable State Service DeUvery Regions (SSDRs). In addition, the notice outlined the following components of the review process: Procedures for filing notices of intent Procedures for obtaining application forms Data survey requirements Filing fee requirements Submission of Certificate of Need (CON) applications Procedures of the review cycle Pursuant to Rule 111-2-2-.08(1 }(c)2, all parties interested in applying under the numerical need provisions were required to file a written notice of intent with the Division no later than the close of business (5:00 P.M ) on Monday, October 16,2006. Applicants were required to Include a defined geographic service area consistent with Rule 111-2-2-.32(2)(c) in their intent notice. Pursuant to Rule 111-2-2- 08(1)(d), all interested parties were required to have in the Division's office a properly submitted application no later than 12:00 P.M., Monday, November 13, 2006, in order to be included in the current batching cycle . . . . . . Pursuant to Rule 111-2-2-.32(3}(b)1, the numerical need for SSDR 12 authorized the consideration of applications for new or expanded home health services. In response, six (6) agencies submitted requests to the Georgia Department of Community Health, Division of Health Planning for issuance of a Certificate of Need for home health services in SSDR 12. The applicants are described as follows: EXHIBlt_~ ~~~(- . " . .. Amedisys Georgia, LLC d/bla Amedisys Home Health of Brunswick (2006-133) seeks to establish a new home health agency serving Glynn and Camden counties, which are located in SSDR 12. These counties show an unmet need of 679 patients Amedisys also seeks to open a branch office in Brunswick, Glynn County, Georgia. The total estimated cost of the proposed project is $185,000. Gentiva Certified Healthcare Corporation d/b/a Gentlva Health Services - Savannah (2006-134) seeks to expand Its home health agency Into Glynn and Camden counties, which are located in SSDR 12. These counties show an unmet need of 679 patients. Gentiva also seeks to open a branch office in 'Brunswick, Glynn County, Georgia. The total estimated cost of the proposed project is $38,269 Island Health Care, Inc. d/b/a Island Health Care (2006-135) seeks to expand its home health agency into Bryan .-and- Bulloch counties, which are located In SSDR 12. These counties show an unmet need of 254 patients. Island also seeks to open a branch office In Statesboro, Bulloch County, Georgia. The total estimated cost of the proposed project is $20,000. Island Health Care, Ine. d/b/a Island Health Care (2006-136) seeks to expand its home health agency into Glynn and Camden counties, which are located In SSDR 12 Island also seeks to open a branch office In Brunswick, Glynn County, Georgia. These counties show an unmet need of 679 patients. The total estimated cost of the proposed project Is $20,000. Premier Home Health Care, LLC d/b/a Harmony Home Health of Coastal Georgia (2oo6-137) seeks to establish a new home health agency serving Glynn and Camden counties, which are located In SSDR 12. These counties show an unmet need of 679 patients. Premier also seeks to open a branch office on St Simons Island, Glynn County, Georgia. The total estimated cost of the proposed project Is $68,000 United Home Care of Coastal Georgia, Inc. (2006-138) seeks to establish a new home health agency serving Glynn and Camden counties, which are located in SSDR 12. These counties show an unmet need of 679 patients. United Home Care of Coastal Georgia, Inc also seeks to open a branch office In Glynn County, Georgia. The total estimated cost of the proposed project Is $228,363 Island Health Care, Inc. d/b/a Island Health Care submitted two (2) applications due to the fact that it was applying to serve both Bryan and Bulloch counties, and Camden and Glynn counties, which are not contiguous sets of counties . PROJECT EvALUA110N The proposals submitted by Amooisys, Gentiva, Island (2006-135 and 2006-136), Premier, and United were reviewed according to the relevant Certificate of Need rules outlined In the General Review Considerations, and the Home Health Services Addendum of the Georgia state Health Plan. The following are the review findings for each of these rules. General Review Considerations Rule 111-2-2-.09(1)(b); The population residing in the area served, or to be served. by the new institutional health service has a need for such services. The Home Health Services Component Plan establishes an objective need methodology for home health selVices based on the utilization of selVices by different age cohorts. Projected future need is determined by an established rate for a defined population cohort. Projected service capacity is then subtracted from the projected need to determine unmet need. This need methodology is outlined In Rule 111-2-2-. 32(3}(a}1 . The Division of Health Planning issued a Batching Review Cycle Notification for Home Health Services on September 14, 2006 in compliance with Rule 111-2-2- 08(1). In this notification, the Division Identified a net SSDR 12 Home Health Batchlng Project Evaluation March 13.2007 Page 2 . .J numerical unmet need of 751 patients in SSDR 12. The sum of only those counties with unmet need in SSDR 12 is 1,124. The Division authorized the submission of applications for new and expanded home health services in the service delivery region based on the submission criteria outlined in Rules 111-2-2- 08(1) and 111-2-2-.32. State service delivery region 12 is comprised of ten (10) counties located in southeast Georgia. Six (6) counties in the region: Bryan, Bulloch, Camden, Chatham, Effingham, and Glynn have an unmet need for home health services. Amedisys, Premier, and United have requested to establish new agencies. Gentiva and Island requested to expand their service area ,,' ..{~~~m~~~;~~!~::j:<,:.s>,)~~~;f~~~~ Pursuant to Rule 111-2-2-.32(2)(b), the three-year planning horizon for the proposed project is 2009. The population projections for the proposed counties in the service area are shown in the table below. The total population within the proposed service area of Amedisys, Gentiva, Island (2006-136), Premier, and United is expected to increase 3.n percent, and that of Island (2006-135) 6.02 percent, based on population projections provided by the Governor's OffIce of Planning and Budget (OPB). Furthermore, the population age 65 and over will increase within the proposed service area of Amedlsys, Gentiva, Island (2006-136), Premier, and United by 10.79 percent, and that of Island (2006-135) 13.54 percent, during the same time period. 10.79% 13.54% Based on the numerical unmet need of 751, the Division has authorized new and expanded home health services in SSDR 12. The applicants have demonstrated an ability to meet the threshold need' for new or expanded home health service by Year 2 in their pro formas. All applicants meet the criteria of this role individually. SSDR 12 Home Health Batchlng Project Evaluation March 13,2007 Page 3 o. ..' r '. Home Health Addendum The numerical need for a new or expanded home health agency in any planning area in the horizon year shall be based on the estimated number of annual home health patients within each health planning area as determined by a population-based formula which is a sum of the following for each county within the health planning area: A a ratio of 4 patients per 1,000 projected horizon year Resident population age 17 and younger; B. a ratio of 5 patients per 1,000 projected horizon year Resident population age 18 throagtrM; C. a ratio of 45 patients per 1,000 projected horizon year Resident population age 65 through 79; and D. a ratio of 185 patients per 1,000 projected horizon year Resident population age 80 and older. The net numerical unmet need for home health services shall be determined by subtracting the projected number of patients for the current calendar year from the projected need for services as calculated ;n (3)(a)(1). The projected number of patients for the current calendar year is determined by multiplying the number of patients having received services in each county, as reported In the most recent survey year, by the county population change factor. The county population change factor is the percent change in total population between the most recent survey year and the current calendar year. As discussed in the evaluation of Rule 111-2-2-.09(1)(b), the Division has detennined a net numerical unmet need of 751 patients and an unmet need of 1,124 In SSDR 12 based on the need methodology outlined In this Rule. Amedisys, Premier, and United have requested to establish new agencies, and Gentiva and Island (2006- 135 and 2006-136) have requested to expand their service areas The table below reflects the unrnet need for home health services for each county In the service area and the counties requested by the applicants. All applicants have proposed to meet the threshold need. Rule 111-2-2-.32(3)(a)1; Rule 111-2-2-.32(3)(a)2: The applicants individually meet the criteria of this rule. Rule 111-2-2-.32(3)(b)1: The Division shall accept applications for review as enumerated below: (i) If the net numerical unmet need in a given planning area is 250 patients or more, the Division shall authorize the submission of applications for an expanded home health agency; or SSDR 12 Home Health Batchlng Project Evaluation March 13, 2007 Page 4 , (ii) ,If the numerical unmet need in a given planning area Is 500 patients or more, the Division shall authorize the submission. of applications for a new home health agency as well as an expanded home health agency An applicant must propose to provide service only within a county or group of counties, each of which reflects a numerical unmet need, and contaIned within . the given planning area for which the Division has authorized the submission of applications. The department shall only approve applications In which the applicant has applied to seNe all of the unmet numerical need In anyone county in which need Is projected. The need within counties shall not be divided or shared between any two or more applicants. In September 2006, the Division authorized the submission of applications for new or expanded home health services in SSDR 12 based on a net numerical unmet need of 751 patients and the unmet need of 1,124 patients in six (6) counties In the service area. As discussed In the evaluation of Rule 11J-2-2-.09(1)(b), the Division has determined that there is need for the proposed project. Amedisys, Premier, and United have requested to establish new home health agencies serving Camden and Glynn counties. Gentiva (Camden and .Glynn) and Island (Camden and Glynn, and Bryan and Bulloch) have requested to expand their existing service area into counties reflecting need. Rule 111-2-2-.32(3)(b)2: Rule 111-2-2-.32(3)(b)3: All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(c)1: The Division may authorize an exception to 111-2-2-.32(3)(a) if: the applicant for a new or expanded home health agency can show that there is limited access In the proposed geographic service area for special groups such as, but not limited to, medically fragile children, newborns and their mothers, and HIV/AIDS patients. For purposes of this exception, an applicant shall be tequired to document, using population, service, special needs and/or disease incidence rates, a projected need for services in the planning 819a of at least 200 patients within a defined geographic service area. A successful applicant applying under this section wiD be restricted to serving the special group or groups Identified In the' application within the county or counties stipulated in the application; or a particular county is seNed by no more than two (2) home health agencies and either of the following concfltions exists: (1) less than one percent of the county's population has received home health services, or (2) one of the two home health agencies has demonstrated a failure to adequately seNe Medicaid patients as evidenced by a level of service to such Individuals that Is less than the statewide average within each of the past two years as reported on the Annual Home Health Services sUNey. For purposes of this exception, an applicant must already be approved to provide seNtee In a contiguous county or be approved to provide service in a county which Is no further than 15 miles from the county authorized through the exception. In all other aspects of the application process, the applicant shall be required to comply with provisions applicable to expanded home health agencies. For purposes of this exception, "seNed only" shall mean the agency(ies) are licensed to seNe the county by the Office of Regulatory SeNices of the Department of Human Resources None of the applicants included in the current batching review cycle for SSDR 12 have applied for a Home Health Services exception as defined in this Rule. Rule 111-2-2-.32(3)(c)2: The criteria ofthis rule are not applicable to the proposed projects. SSDR 12 Home Health Batchlng Project Evaluation March 13, 2007 Page 5 " , Rule 111-2-2-.32(3)(d): An applicant for a new or expanded home health agency shall provide a community linkage plan which demonstrates factors such as, but not limited to, referral arrangements with appropriate setVices of the health care system and woridng agreements with other related community selVicas assuring continuity of care focusing on coordinated, integrated systems which promote continuity rather than acute, episodic care. Working agreements with other related community setVices may include the ability to streamline referrals to other appropriate services and to participate in the development of cross-continuum care plans with other providers. Amedisvs Amedisys provided a detailed three-phased approach to establishing a continuum of care network which consists of an introductory contact followed by an open house, and finally a marketing blitz In its application, Amedisys provided letters of support for Its bid to provide services to Camden and Glynn counties. The applicant also submitted copies of business cards from providers it had contacted In the area. Additionally, the applicant stated that It mailed letters to 134 physicians and 38 community agencies affirming its desire to provide services In the two-county area. Gentiva As an existing provider in the planning area, Gentiva provided a detailed and extensive list of contacts it Initiated. The applicant also provided a number of "Refenal Interest Agreements" which It utilizes to establish relationships with other health care providers. The applicant also plans to use its linkage strategy/plan to help in achieving its 3 percent commitment. Island For both of its applications. Island (2006-135 and 2006-136) provided numerous letters of support, as well as an extensive list of Initiated contacts and existing provider relationships. The applicant stressed that It is In of Itself a part of a continuum of care as it provides private home life care services and hospice care Premier Premier provided a number of letters of support However, most of these letters originate from non-health care providers The applicant did provide an extensive list of health care providers it made "face-to-face- contact with. United United provided numerous letters of support supporting its application to provide services to Camden and Glynn counties. United also submitted a list of established contacts, including company-owned health care entities which offer a continuum of care. The DMsionfinds that community linkage plans and efforts toward establishing linkages presented by all the applicants meet the requirements to establish community linkages within their respective service areas. All applicants minimaliy meet the criteria of this rule. An applicant for a new or expanded home health agency shall provide a written statement of its intent to comply with all appropriate licensure requirements and operational procedures' required by the Office of Regulatory SelVfces of the Georgia Department of Human Resources.. Home Health facilities in Georgia are required to meet minimum operational standards in order to ensure that citizens receive a quality level of service, These standards are defined in the licensure rules and operational procedures established by the Georgia Department of Human Resources, Office of Regulatory Services. The Rule 111-2-2-.32(3(e); SSDR 12 Home Health Batchlng Project Evaluation March 13, 2007 Page 6 " . . , applicants In the current batching review cycle for SSDR 12 have stated their intent to comply with appropriate licensure requirements and operational procedures Aft applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(fJ: An applicant for a new or expanded home health agency or agency(ies) owned and/or operated by the applicant or its parent organization shall have no history of uncorrected or repeated conditional level violations or uncorrected standard deficiencies as Identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. All applicants state that neither they, nor their parent organization has a history of uncorrected or repeated conditional level deficiencies or uncorrected standard deficiencies as identified by licensure inspections or equivalent deficiencies as noted from Medicare or Medicaid audits. Applicants with existing operation provided documentation from the Department of Human Resources which verifies that none have regulatory deficiencies. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(0): An applicant for a new or expanded home health agency or agency(fes) owned and/or operated by the applicant or its parent organization shall have no previous conviction of Medicaid or Medicare fraud. All applicants have stipulated that neither they nor their parent organizations have previous convictions of Medicaid or Medicare fraud. All applicants meet the criteria of this rule. An appncant for a new or expanded home health agency shall provide a written plan which demonstrates the intent and ability to recrolt, hire and retaIn the appropriate numbers of qualified personnel fo meet the requirements of the selVices proposed to be provided and that such personnel are avaHable in the proposed geographic setvice area. The chart below details the projected full-time equivalent (FTE) staffing needs by Year 2 of project Implementation Rule 111-2-2-.32(3)(hJ: SSDR 12 Home Health Batchlng Project Evaluation March 13, 2007 Page 7 " , PROJECIED SIAFFING LEVELS (FIEs) 33 30 n .AI lIlI Nursing ~: Home Health BatchinQ AppIicatJon. SSDR 6 All applicants have developed a staffing needs assessment and recruitment and retention strategies for both full time and contract staff. The applicants Intend to recruit staff from local resources, Including the pool of part-time nursing professionals, Internal postlngs, community service organizations, other healthcare providers, job fairs, and area Institutions of higher education. In addition, applicants will utilize networking relationships established through their parent organizations to recruit staff from clinical staffing agencies. Retention efforts wl1l focus primarily on thoughtful hiring, job training, competitive benefits, open communication, quality improvement, and continuing educationltraining. However, based on the applicants' projections, Island (2006-1.35 and 2006-136), and Premier will provide the least amount of total visits and visits per patient by year 2. SSDR 12 Home Health Balchlng Project Evaluation March 13, 2007 Page 8 , Total Home Health Visits Prolected byYear 2 SSDR12 D 18000 17000 16000 . 15000 " 14000 WI 13000 g 12000 Iii WI 11 000 e ~ 10000' o 9000 ~ 8000 'ii 7000 . 6000 5000 4000 3000 Amedlsys Gentiva Island (135) Island (136) Premier UnIted Source SSDR 12 Home Health Applications According to the DMslon's data. the average number of home health visits per patient In SSDR 12 from 2003 to 2005 has been 17.01, 16.54, and 16.68, respectively_ Island projects 14.24 visits per person (2006-135 and 2006-136); Premier projects 16.14 visits per person; Amedisys projects 23.16 visits per person; Gentiva projects 18.68 visits per person; United projects 176 visits per person. Both Island (2006-135 and 2006-136) and Premier's projected number of visits falls short of the historical levels of service provided In the SSDR. All applicants meet the criteria of this rule. Island (2006-135 and 2006-136) and Premier minimally meet the criteria of this rule. Rule 111-2-2-.32(3)(i}: An applicant for a new home health agency shall provide evidence of the intent to meet the appropriate accreditation requirements of the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc. (CHAP), and/or other appropriate accrediting agencies. Accreditation by a recognized body such as JCAHO or CHAP indicates that an organization meets certain performance standards that enable it to provide quality patient care. As applicants for new home health agencies, Amedisys and Premier stated their intent to seek accreditation from JCAHO. United received a conditional accreditation from JCAHO. Gentiva and Island (2006-135 and 2006-136) meet the criteria of this rule. This rule is not applicable to Ainedisys and Premier. United does not meet the criteria of this rule due to its conditional accreditation. SSDR 12 Home Health Batchlng Project EvaluatIon March 13,2007 Page 9 " , . An applicant for an expanded home health agency shall provide documentation that they are fully accredited by the Joint Commission for Accreditation of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Ine (CHAP), anellor other appropriate accrediting agency. As noted in the evaluation of the previous rule, accreditation by a recognized body indicates that an organization meets certain performance standards that enable it to provide quality patient care. As the two major accreditation bodies. JCAHO and CHAP are recognized nationally for standards' that 'reflect high-level performance expectations. In order to ensure that suCh a level of quality exists in home health services that are awarded a CON, accreditation by such a body is required for the expansion of existing home health agencies. Rule 111-2-2-.32(3)(i): Gentiva and Island submitted documentation of their accreditation from JCAHO All applicants meet the criteria of this rule. An applicant for a new or expanded home health agency shall provide its existing or proposed plan for a comprehensive quality improvement program. The Home Health Services Component Plan states that providers should have quality improvement programs consisting of outcomes data and up-to-date Industry benchmarks that address patient outcomes, consumer satisfaction and demand, and patient/consumer rights. Rule 111-2-2-.32(3J(kJ: Amedisvs Amedisys submitted a plan for a comprehensive quality improvement program that is taken from the existing plan used by other Amedisys agencies. The program Is evidence of a commitment to identify and improve processes which enhance quality, efficiency, and appropriateness of services rendered. Gentiva Gentiva submitted a draft quality improvement plan. The objective of the plan is to promote consistent patient care on a continual basis, ~d to promote effective and efficient utilization of Its facilities and services. Island (2006-135 and 2006-136) Island submitted a comprehensive quality Improvement program which focuses ongoing monitoring activities, proactive risk assessment, data reporting and collection, and program effectiveness. Premier Premier provided a draft quality improvement program which focuses on patient satisfaction, patient safety, and providing optimal conditions for patient recovery The plan centers on outcome-based quality improvement. United United provided the plan utilized by UHC which uses quality indicators from the OASIS data set, consumer surveys, compliance surveys, and internal quality checks. All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(1): An applicant for a new or expanded home health agency shall assure access to services to individuals unable to pay and to all individuals regardless of payment source or circumstances by: 1. providing evidence of written administrative policies that prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or ability to pay; SSDR 12 Home Health Batching Project Evaluation March 13, 2007 Page 10 " , 2.. 3. 4 5. Rule 111-2-2-.09(1)((1): providing a written commitment that services for Indigent and charity patients Wl71 be offered at a standard which meets or exceeds three percent of annual, adjusted gross revenues for the home health agency or, in the case of an appNcant providing other health services, the applicant may request that the DMsion allow the commitment for services to Indigent and charity patients to be applied to the entire facility; providing documentation of the demonstrated petformance of the applicant, and any facility in Georgia owned or operated by the applicant's parent organization, of providing services to Medicare, Medicaid. and indigent and charity patients; providing a written commitment to participate in the Medicare, Medicaid and Peach Care programs; and providing a written commitment to participate in any other state health benefits insurance programs for which the home health service is eligible. The new institutional health service proposed Is reasonably financially and physically accessible to the residents of the proposed service area and will not discriminate by virtue of race. age. sex, handicap, color, creed, or ethnic affiliation. All applicants provided copies of their indigent care and nondiscrimination policies designed to prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or abDity to pay. Additionally, the applicants stated their intent to continue to participate in the Medicare and Medicaid programs and stipulated their commitment to participate in any other state health benefit insurtmce programs for which home health services are eligible In addition to the review of administrative pollees, the Division evaluates the extent to which an applicant is financially accessible to the residents of its service area ThIs Includes an evaluation of the appllcanfs participation in the Medicare and Medicaid programs, and provision of services to low Income and indigent patients. In 2005, 91 30 percent of the total visits conducted by Amedisys in Georgia were Medicare patients, while 2.79 percent of the visits were Medicaid patients 6115 percent of the total visits conducted by Gentiva were Medicare patients, while 2.80 percent of the visits were Medicaid patients.. For Island, 18.4 percent of the vislts were Medicare patients, and 5-4 percent were Medicaid Visits Medicare accounted for 90..39 percent of United's visits, and Medicaid accounted for 2.74 percent. Premier is a new agency, and consequently has no established record of service. In evaluating financial accessibility, the Department evaluates the applicant's level of indigent and charity care commitment for the previous three (3) years. According to the Division of Health Planning. in 2003, Amedisys provided .45 percent of its adjusted gross revenues (AGR) in direct service Indigent and charity care. In 2004 and 2005, Amedisys provided .73 percent and .1.52 percent, respectively, of its AGR in direct service indigent and charity care. Gentiva provided 1.5 percent in indigent care in 2003. 2 36 percent in 2004, and 2.60 percent in 2005. Island provided .05 percent In 2003,0 percent in 2004, and 0 percent In 2005. United provided 3.0 percent in 2003. 292 percent in 2004, and 2.25 percent in 2005. Premier, being a new agency, has no record of service. All applicants made the mandatory 3 percent commitment. The commitment is reflected in the applicant's pro forma and stated in the application The Division utilizes a 3 percent commitment as an acceptable level of indigent and charity care This issue was addressed at the 60 Day Meeting. All applicants were Instructed to address their plan for meeting the commitment. Additional information was received from all applicants SSDR 12 Home Health Batchlng Project Evaluation March 13. 2007 Page 11 , , , .. The DMslon will continue to monitor the performance of agencies which desire to expand or establish a new agency. All applicants minimally meet the criteria of this rule. An applicant for a new or expanded home health agency shall demonstrate that their proposed charges compare favorably with the cliarges' of existing home health agencies In the same geographic service area. All applicants have projected that the majority of their services will be rendered to Medicare patients. Given the fIXed rate prospective payment system that has been implemented for Medicare reimbursement. all agencies In the service area will be paid at the same rate regardless of their charge structure. Rule 111-2-2-.32(3)(m): All applicants meet the criteria of this rule. An applicant for a new or expanded home health agency shall document an agreement to provide Division requested information and statistical data related to the operation and provision of home health services and to report that data fo the Division In the time frame and fannat requested by the Division. Uniform data Is important to assess changing patterns and projected service needs relevant to the provision of home health services. Furthermore, data enables the Division to analyze quality, patient outcomes, and community benefit All applicants have stated their intent to provide information and data related to their home health services In the required time frame and format requested by the DMsion Rule 111-2-2-.32(3)(n): All applicants meet the criteria of this rule. Rule 111-2-2-.32(3)(0): The department may authorize an existing home health agency to transfer one county or several counties to another existing home health agency without either agency being required to apply for a new or expanded certificate of need, provided the foRowing conditions are met 1. the two agencies agree to the transfer and submit such agreement and a joint request to transfer In writing to the department at least thirty (30) days prior to the proposed effect/ve date. of the transfer; 2.. the two agencies document within the written request that the transfer would result in increased and improved services for the resfdents of the county or counties including Medicare and Medicaid patients; 3. the agency to which the county or counties are befng transferred currently offers services in at least one contiguous county or within the health planning area(s) in which county or counties are located; and 4. the two agencies are in compliance with all other requirements of these Rules; such compliance to be evaluated with the written transfer request. No such transfer shall become effective without written approval from the department. The proposed project does not involve the acquisition of an existing agency, transfer of counties between agencies or the merger of agencies, SSDR 12 Home Health Batching Project Evaluation March 13,2007 Page 12 " , The criteria of this rule are not applicable to the proposed projects. General Review Considerations continued Existing alternatives for providing services in the service area the sarne 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. According to information compiled from the 2005 Annual Home Health Survey, there are eight (8) home health agencies In SSDR 12 These agencies provided 126,919 visits to 7,463 patients. Despite the existence of these agencies and the level of home health care services provided, the DMslon has determined a numerical unmet need for home health services In six (6) counties of SSDR 12 based on the need methodology outlined In Rule 111-2-2-.32(3)(a)1. There are no other alternatives to the proposal submitted by the applicant. Rule 111-2-2-.09(1)(c): All applicants meet the criteria of this rule Rule 111-2-2-.09(1)(d): The project can be adequately financed and Is, In the Intermediate and long- tenn, financially feasible. Amedlsvs Amedisys estimates a total project cost of $185,000. The proposed project will be financed through available cash balances. John F. Gilbin, Chief Financial Officer of Amedisys, Inc., verified the availability of funding. The applicant anticipates that the project will be Implemented no later than July 2007 By Year 2, the applicant projects net Income of $177,555, serving 679 patients, and averaging 23.16 visits per patient. Gentiva Gentiva estimates a total project cost of $38,269. The proposed project will be financed through unrestricted reserves. Tony Strange, Executive Vice President and President of Gentlva Home Health verified the availability of funding. The applicant anticipates that the project will be implemented no later than June 2007 By Year 2, the applicant projects net income of $203,770, serving 679 patients, and averaging 18.68 visits per patient Island (2006-136) Island estimates a total project cost of $20,000. The proposed project will be financed through a loan from Darby Bank & Trust Company The applicant anticipates that the project will be implemented no later than July 2007. By Year 2. the applicant projects net income of $226.350. serving 679 patients, and averaging 1424 visits per patient. Island (2006-135) Island estimates a total project cost of $20.000_ The proposed project will be financed through a loan from Darby Bank & Trust Company The applicant anticipates that the project will be implemented no later than July 2007 By Year 2, the applicant projects net income of $74.955, serving 254 patients. and averaging 14.24 visits per patient Premier Premier estimates a total project cost of $68.000. The proposed project will be financed through a loan from Sun Mark Community Bank. The applicant anticipates that the project will be implemented no later than September 2007 By Year 2. the applicant projects net income of $238,530, serving 679 patients, and averaging 16.14 visits per patient. SSDR 12 Home Health Batchlng Project Evaluation March 13. 2007 Page 13 .. , United United estimates a total project cost of $228,363. The proposed project will be financed through cash resEllVes. Greg Wren, CFO for Pruitt Corporation verified the availability of funding. The applicant anticipates that the project win be implemented no later than July 2007. By Year 2, the applicant projects net Income of $126,643, 679 patients, and averaging 17.6 visits per patient According to the Division's data, the average number of home health visits per patient In SSDR 12 from 2003 to 2005 has been 17 01,16.54, and 16.68, respectively. Island (2006-135 and 2006-136) projects 1424 visits per person; Premier projects 16.14 visits per person; Amedisys projects 23.16 visits per person; Gentiva projects 18.68 visits per person; United projects 17.6 visits per person. Both Island and Premier's projected number of visits falls short of the historical levels of service provided In the SSDR. All applicants meet the criteria ofthis rule. Rule 111-2-2-.09(1)(e): The effects of the new institutional health service on payors for health services, Including governmental payors, are reasonable. The Division has determined a need for home health services in SSDR 12, and the costs associated with the projects proposed by the applicants have been determined to be reasonable. Furthennore, as discussed in the evaluation of Rule 111-2-2-.32(3)(m), the fixed rate prospective payment system of Medicare ensures that all home health providers in a geographic service area are reimbursed for their services at the same amount, regardless of charges Therefore, the services proposed by Amedisys, Gentiva, Island (2006-135 and 2006- 136), and Premier should not result In an unreasonable increase in either the Medicaid or Medicare payment rate of payors for home health services. The Division has determined that the effects of the proposed projects for these organizations on payors are reasonable. United Home Care does not satisfy this rule because it failed to meet Rule 111-2-2-.32(3)(i), which requires JCAHO accreditation. . . Amedisys, Gentiva, Island (2006-135 and 2006-136), and Premier meet the criteria of this rule. United does not meet the criteria of this rule Rule :111-2-2-.09(1)(f): The costs and methods of a proposed construction project, including the costs and methods of energy provision and conselVation, are reasonable and adequate for quality health care. Construction plans will be reviewed in detail to assure that space is designed economically. Space shelled-in for some future use will not be accepted unless the applicant demonstrates that the shelled-in space will not be directly related to the provision of any clinical health service. The nature of home health services requires that the majority of care be provided in the homes of patients. Consequently, the proposed projects do not involve any construction to Implement. All applicants either have All of the applicants have provided verification of the availability of the proposed sites for their administrative offices. The criteria of this rule are not applicable to the proposed projects. SSDR 12 Home Health Batchlng Project Evaluation March 13,2007 Page 14 .. , . The proposed new Institutional health selVice has a positive relationship to the existing health care delivery system in the seNice area. Applications for new or expanded home health services were filed in response to a need Identified by the Division, through a batching notice. The proposals as submitted by the applicants are Intended to address this identified need. Home health Is a very specific, specialized type of home care that focuses on a specific type of patient, those who are transitioning out of an acute care setting or those who are unable to care for themselves . k. such, the lack of available home health care services could potentially lead to greater utilization of more costly long term care alternative, such as nursing home care, which in general is a more expensive health care alternative. New institutional health services that fundamentally meet the rule criteria can be reasonably expected to have a positive relationship to the existing health care delivery system in the service area. However, United failed to satisfy Rule 111-2-2-.32(3)(i) pertaining-to-JCAHO accreditation, and therefore, fails to meet this role. Rule 111-2-2-.09(1)(h): Amedisys, Gentiva, Island (2006-135 and 2006-136), and Premier meet the criteria of this rule. United does not meet the criteria of this role. The proposed new Institutional health selVices are reasonably consistent with the relevant general goals and objectives of the State Health Plan. The Home Health Services Component Plan states the following goal: "to ensure that Georgia citizens have access to cost-effective, efficient, and quality home health services.- Due to the competitive nature of the home health batchlng review process, the Division carefully evaluates the proposals to determine the best alternative to meet the needs of the service area. Factors such as historical financial accessibility with regard to indigent and charity care, Medicare and Medicaid provision, community linkages, and quality of service are heavily weighed to determine the project with the optimal benefrt to the service area. Rule 111-2-2-.09(1)(a): Amedlsys, Gentiva, Island (2006-136), and Premier have demonstrated their ability to meet this goal as evidenced by the fact that they have met all the criteria of the relevant rules contained in the General Review Considerations and Home Health Services Addendum of the State Health Plan. Consequently, further review under Rule 111-2-2-.08(1)(h) is required to determine the best proposal to meet the numerical unmet need in SSDR 12. Island (2006-135) has demonstrated its ability to meet all the criteria of the relevant rules contained in the General Review Considerations and Home Health Services Addendum of the State Health Plan. It is the only applicant seeking to service Bryan and Bulloch counties, and not involved in the competitive process. It will therefore not be involved in the tiebreaker rule (Rule 111-2-2-.08(1)(h). United Home Care will not be Involved in the tiebreaker due to not meeting the criteria of the following rules: + 111-2-2-.32(3)(i) + 111-2-2-.09(1)(e) + 111-2-2-..09(1)(h) Rule 111-2-2-.08(1)(h); In evaluating batched applications, if any or all of the batched applications equally meet the statutory considemtions, priority consideration will be given to a comparison of the applications with regard to; 1. The past and present records of the facility, and other existing facilities in Georgia, if any, owned by the same parent organization, regarding the provision of service to all segments of the population, particularly including Medicare, Medicaid, minority patients and those patients with limited or no ability to pay; SSDR 12 Home Health BatchIng Project EvaluatIon March 13, 2007 Page 15 .. In its evaluation of Rule 111-2-2-.32(3)(J) and Rule 111-2-2-.09(1J(oJ, the Division discussed the level of Medicare, Medicaid, and Indigent and charity care provision of the applicants. In 2005, 91.30 percent of the total visits conducted by Amedisys in Georgia were Medicare patients, while 2 79 percent of the visits were Medicaid patients 61.15 percent of the total visits conducted by Gentiva were Medicare patients, while 280 percent of the visits were Medicaid patients. For Island, 78 4 percent of the visits were Medicare patients, and 5.4 percent were Medicaid VISits. Premier Is a new agency, and consequently has no established record of service. According to the Division of Health Planning, in 2003, Amedisys provided .45 percent of its adjusted gross revenues (AGR) In direct service indigent and charity care. In 2004 and 2005, Amedisys provided .73 percent and .1 .52 percent, respectively, of its AG R in direct service indigent and charity care. Gentiva provided 1.5 percent In indigent care In 2003,2.36 percent in 2004, and 2.60 percent in 2005 Island'provided .05 percent in 2003,0% in 2004, and 0% in 2005. Premier, being a new agency, has no record of service. Although Gentlva did not meet its indigent and charity care commitment for 2005, it provided the highest percentage of care In SSDR 12 Gentiva best meets the criteria of this role. 2. Specific selVices to be offered. All applicants are proposing a variety of specialized home care services. All applicants meet the criteria of this role. Island (2006-136) and Premier are proposing minimal visits. 3 Appropriateness of the site, i.e., the accessibility to the population to be served, avallabflity of utilities, transportation systems, adequacy of size, cost of acquisition, and cost to develop; As discussed in the evaluation of Rule 111-2-2-.09(1Jfn. the applicants have proposed leasing office space. As such, there are no associated acquisition or development costs. Furthermore, home health services are delivered to IndMduals In their place of residence and are thus highly accessible to the population to be served. The criteria of this role are not applicable to the proposed projects. 4 Demonstrated readiness to Implement the project, incfuding commitment of financing; . To evaluate the applicants' readiness to Implement the project, the Division reviewed the availability of funds and the applicanfs preparation to develop or expand its service in SSDR 12. As discussed in Rule 111-2-2-.09(1)(dJ, the applicants have adequately documented the availability of funds needed to implement the proposed projects. In the Division's review of Rule 111-2-2-.32(dJ. the applicants provided community linkage plans to demonstrate the steps they have taken to develop relationships in their new service areas and a strategy for fostering these relationships in the future. Due to the competitive nature of this process, the strengths of the community linkage plans are a significant factor in the review process. For those applicants vying for Glynn and Camden counties, Gentiva's three-step approach, along with its "Referral Interest Agreements" clearly demonstrated the effort It placed In Implementing such a plan. Although all applicants demonstrated efforts in laying a foundation on which to develop community relationships, Gentiva's plan solidly laid a plan for the present and the future. Gent/va best meets the criteria of this role.. Amedisys, Island (2006-136). SSDR 12 Home Health Batchlng Project Evaluation March 13, 2007 Page 16 .. " . 5. Pattems of past petfonnance, If any, of the applicants in Implementing previously approved projects in a timely fashion; For Amedisys, Gentiva, and Island, there is no indication that their past performance in implementing previously approved projects has been anylhing but according to timeframes as required by the Division. Premier is new, and do not have a record of past perfoonance. All applicants meet the criteria of this rule. 6. Past record, if any, of the applicant facility, and other existing facilities owned by the same parent organization, If any, In meeting licensure requirements and factors relevant to providing accessible, quality health care; In its evaluation, the Division reviews the current record of the applicant or affiliate in meeting licensure requirements. The Division has verified that none of the applicants has current. uncorrected licensure deficiencies. All applicants meet the criteria of this role. 7. Evidence of attention to factors of cost containment, which do not diminish the quality of care or safety of the patient, but which demonstrate sincere efforts to avoid significant costs unrelated to patient care; and Home health by its very nature is a more cost effective alternative in health care as is evidenced by the proposed costs and charges. For Gentiva and Island, who are seeking further expansion in SSDR 12. the additional proposed counties will allow them to spread overhead and administrative costs over a larger patient base, thereby reducing administrative costs. Island plans to utflZe Telehealth as a cost effective alternative. Premier plans to reduce costs through case management, and the use of contract staffing. This will allow them to add staff on an -as neede~ basis. Amedisys plans to reduce the number of home care visits per episode of care through DSM protocols that improve patient outcomes. All applicants meet the criteria of this rule. 8. Past compliance, if any, with survey and post-approval reporting requirements and indigent and charity care commitments. All applicants have been compliant with past survey and post approval reporting requirements. None of the applicants has been able to meet their indigent and charity care commitment through the direct provision of care. All have been compliant in the payment of shortfall amounts. Gentiva provides the highest of indigent/charity care in SSDR 12 Gent/va best meets the criteria of this rule. Based on the documentation provided, and following application of the tiebreakers, Genth,a has been determined to be most consistent with all relevant goals and objectives of the State Health Plan for Glynn and Camden counties. - SSDR 12 Home Health Batching Project Evaluation March 13, 2007 Page 17 .. CONCLUSION Based on the evaluation of the findings of the relevant CertifICate of Need Rules, for this project, it is the decision of the Georgia Department of Community Health, Office of General Counsel to ISSUE a Certificate of Need to Gentiva Certified Healthcare Corporation d/b/a Gentiva Health Services - Savannah for Glynn and Camden counties In SSDR 12. and Island Health Care, Inc_ d/b/a Island Health Care (2006-136) for Bryan and Bulloch counties in SSDR 12. Additionally, it is the decision of the Georgia Department of Community Health, Division of Health Planning to DENY a Certificate of Need to Amedisys Georgia. LLC d/b/a Amedisys Home Health of Brunswick, Island Health Care. Inc. d/b/a Island Health Care (2006-136), Premier Home Health Care. LLC d/b/a Harmony Home Health of Coastal Georgia, and United Home Care of coastal Georgia, Inc. Additionally, the certificate Is valid for a period of twelve (12) months, unless extended for good cause. It is important that the administration of your project be consistent with the Certificate of Need rules. Accordingly, a copy of "Post Approval Requirements, n which outlines the duration, progression, and extension provisIons (if needed) that apply to this approval Is available at the Department's website: www.dch.aeoraia.aov. Please be advised that a decIsIon by the Department is subject to appeal withIn thIrty (30) days from the date It is rendered. Should a bona fide request for an appeal be received, you will be promptly notified and the Certificate of Need will be suspended until the appeal is resolved. You are strongly advised not to make a substantial obligation of funds until the time period for requesting an appeal has expIred. The approval of a project by the Department of Community Health, Office of General Counsel does not assure that any amount or rate of reimbursement will be paid by the DivIsIon of Medical Assistance, the Medicare intermedIary, or any other payment source. SSDR 12 Home Health Batchlng Project Evaluation March 13, 2007 Page 18 .. WILLIAM C. JOY ATTORNEY AT LAW 5349 Rosser Road Stone Mountain, Georgia 30087 770-491-7754 wcjoy@ bellsouth.net July 14, 2007 Robert M. Rozier, Esq. Executive Director Division of Health Planning Department of Community Health 2 Peachtree Street N.W., 5th Floor Atlanta, Georgia 30303-3142 Re: Gentiva Certified HealthCare Corp. & United Home Care of Coastal Georgia Project NO. GA 2006-134 & Project NO. GA 2006-138 Dear Mr. Rozier, Enclosed please find for filing an Order granting United's Motion to Remand and Remanding the case to the agency for further review and findings. I am sending copies of this Order to the attorneys for the interested parties. I appreciate your help with this matter. Sincerely, /II~C:J~ William C. Joy Hearing Officer cc: wi ends: Alex F. Sponseller, Esq. Victor L. Moldovan, Esq. Charles L. Gregory, Esq. EXHIBIT"fL- .' STATE HEALTH PLANNING REVIEW BOARD STATE OF GEORGIA IN RE: GENTIV A CERTIFIED HEALTH CARE CORP. d/b/a GENTIV A HEALTH SERVICES-SAVANNAH PROJECT NO. GA 2006-134 UNITED HOME CARE OF COASTAL GEORGIA, INC PROJECT NO. GA 2006-138 ORDER ON MOTION TO REMAND The foregoing matter has come before the undersigned Hearing Officer on a motion to remand filed by Appellant United Home Care of Coastal Georgia, Inc. (hereinafter "United") and opposed by the Department of Community Health ("Department" or "DCH") and Gentiva Certified Healthcare Corp. d/b/a Gentiva Health Services-Savannah (hereinafter "Gentiva"). Oral argument via teleconference was heard on July 3,2007. After considering the briefs, the undisputed evidence, and the arguments of the parties, the Hearing Officer accordingly finds and concludes the following. .. FINDINGS OF FACT 1. On September 14, 2006, the Department published a Batching Review Cycle Notification for home health services identifying six (6) counties with unmet need for home health services in State Service Delivery Region 12 (hereinafter "SSDR 12"). See Rules 111-2-2-.08(1) and 111-2-2-.32. In response to the notice, five (5) applicants filed six (6) applications proposing to serve some of the identified counties. See Department Decision. 2. These applicants included: United, Gentiva, Island Health Care, Inc. d/b/a Island Health Care (hereinafter "Island"), Amedisys Georgia, LLC d/b/a Amedisys Home Health of Brunswick (hereinafter "Amedisys"), and Premier Home Health Care, Inc. d/b/a Harmony Health of Coastal Georgia (hereinafter "Premier"). Id. All the applicants proposed to serve Glynn and Camden counties. Island also separately applied to serve Bryan and Bulloch counties. Id. 3. Appellant United was formed on October 16, 2006, and on November 13, 2006 United filed a Certificate of Need ("CON") Application (Project No. GA 2006-138) to establish a new home health agency serving Glynn and 2 Camden Counties located in SSDR 12. See United Application, Section 1, p. 4. Appellant United is also wholly owned by United Health Services of Georgia, Inc. which is itself wholly owned by United Health Services, Inc. See id. United Health Services also owns and operates four other home health agencies under the United Home Care name ("UHC") or called the UHC System. Id. 4. While the four home health agencies and United itself proposed to operate as divisions of UHC, all throughout United's Application it clearly stated: UHC-Coastal Georgia is committed to delivering quality home health care to the proposed service area and will seek JCAHO accreditation as soon as possible after initiation of services. Id. at Section 3, p. 9.2 (See also, pp. 10.8, 11.11, 11.26, and Section 4, p. 36.7) 5. United's Application also clearly stated two important facts regarding its status as an applicant. First, in response to DCH's Rule 111-2-2-.32(3)(i) governing "new" home health agencies, United stated: All four home health agencies currently operated as affiliates ofUHS- Pruitt are currently accredited by JCAHO and UHS-Pruitt and the 3 applicant are committed to ensuring that the proposed new home health agency meets the appropriate accreditation requirements of lCARO. rd. at Section 4, p. 36.7 Second, in response to DCR's Rule 111-2-2-.32(3)0) governing "expanded" home health agencies, United stated: Not applicable. URC-Coastal is not applying for an expansion. rd. 6. Although United clearly stated that it was applying as a new home health agency and not as an expended heath agency and that it would meet the "appropriate accreditation standards", United also relied upon the status of its affiliates and overstated their status with lCARO throughout the application by stating they were "fully accredited." rd. at Section 3, pp. 9.2, 10.8, 11.11. The problem was that at the time these statements were made and continuing until May 21,2007, two months after the Department's decision, United's sister affiliates, operating as a system under UHC, were only "conditionally" accredited, as shown by documents supplied by United in its application and afterwards. See letters from lCARO dated August 16, 2006; March 1,2007 and May 21,2007. lCARO's letter of March 1,2007 confirmed URC's conditional status, but also showed that it was attempting to obtain full accreditation. 4 7. The Department issued its decision on March 13,2007, and awarded a CON to Gentiva to expand into Glynn and Camden Counties and also awarded a CON to Island to expand into Bryan and Bulloch counties. Island moved to sever its Project from this appeal and its motion was granted. It is not affected by this Order. 8. The Department correctly noted that "United seeks to establish a new home health agency serving Glynn and Camden counties...." Decision, p. 2. In the Department's analysis of the Rule governing "new" home health agencies, the Department stated: As applicants for new home health agencies, Amedisys and Premier stated their intent to seek accreditation from lCARO. United received a conditional accreditation from lCARO. Id. at p. 9 9. As noted in Findings of Fact 4 and 5, however, United also clearly stated its intent to seek accreditation from lCARO, and this statement was not referenced in the Department's decision noted above; but rather the conditional status ofURC was attributed to United, and its statements to 5 meet lCARO accreditation were overlooked and omitted by the Department in its analysis of the requirements for new home health agencies. Id at p. 9. 10. As a result of the Department's analysis, it denied United's application as a "new" home health agency and precluded United from being considered in the "tiebreaker" considerations of Rule 111-2-2-.08(1)(h). Id. at p. 15 11. United filed its appeal on lune 6, 2007, and later filed a motion to remand based on its contention that this case should be remanded because the Department "erroneously determined that United did not satisfy the criteria of the applicable rule regarding accreditation requirements of [lCARO]." United's Motion to Remand, p. 1. The Department and Gentiva opposed United's motion contending that the conditional accreditation status of United's sister affiliates, acting as a system under URC, was attributable to United as a new home health agency. 6 ~ CONCLUSIONS OF LAW 1. The hearing officer is empowered to issue an order remanding the case to the Department "for further review and consideration" pursuant to Rule 274-1-.10(7). This power has been exercised in the past so the Department may be given the opportunity to correct or modify its decision when errors were made in the original decision, which were material to the decision on appeal. .ag., In Re: Amedisys Georgia, LLC. d/b/a! Amedisys of Southwest Georgia. et aI, Project NO., 2005-093-099. A remand is necessary to correct errors when a party has been unfairly precluded from full consideration of its CON application, because of errors in the original decision, which may be efficiently corrected and returned to the hearing officer prior to proceeding through the entire hearing and appeal process. Id. 2. The burden of proof is on the appellant or movant in this case. Rule 274-1-.09(5). Also, to the extent the hearing officer is reviewing Department decisions that are matters of policy or constitute the Department's interpretation of the CON statute and rules, these matters are entrusted to the agency's discretion and are entitled to deference. See. 7 Department of Community Health v. Satilla Health Services, Inc., 266 Ga. App. 880 (2004); Rule 274-1-.08(3). 3. The two primary rules at issue are the rules governing what applicants must show to become a "new" or "expanded" home health agency. Rule 111-2-2-.32(3)(i) provides: An applicant for a new home health agency shall provide evidence of its intent to meet the appropriate accreditation requirements of the [JCAHO].. .." Rule 111-2-2-.32(3)0) provides: An applicant for an expanded home health agency shall provide documentation that they are fully accredited by the [JCAHO].. .." 4. Had United applied as an expanded home health provider under its sister affiliates' conditional status with JCAHO at the time the Department was considering its application, the Department's decision on this issue could be easily affirmed. It did not, however. It clearly applied as a "new" provider, and the question presented is what is the meaning of the phrase "evidence of intent to meet appropriate accreditation requirements of [JCAHO]" under Rule I 11-2-2-.32(3)(i). Consideration of this question 8 must be made in the context of the very next subsection concerning "expanded" home health agencies, which are required to show that they are "fully accredited" by JCAHO. Rule 111-2-2-.32(3)(j). The obvious reason for the difference in the wording of the two subsections is that new agencies cannot show full accreditation until they undergo the review process by JCAHO, which requires inspection time after they obtain a CON and are able to legally operate. As noted by the parties, there are several levels of accreditation and progression from "conditional" to "provisional" to "accreditation" involves a continuous review process involving follow up visits by the reviewers. This review process, out of necessity, may take months and for that reason it would be impossible for a new home health agency to attain full accreditation before obtaining a CON and beginning operations. 5. Both the Department and Gentiva correctly note that the "cardinal rule" of statutory construction is to ascertain the legislative intent and purpose in enacting a statute and construe it in a way that will effectuate that intent and purpose. See, Medical International, Inc. v. Charter Lake Hospital, 186 Ga. App. 204, 206 (1988). This rule may also be applied to construing rules promulgated pursuant to statutes; and, as noted by the 9 parties, the purpose of the "Accreditation Rule" is to require the applicant to commit to a certain level of care to its patients by seeking review and accreditation. In addition, "[i]t is an elementary rule of statutory construction that a statute must be construed in relation to other statutes of which it is a part, and all statutes relating to the same subject matter.. . are construed together." Mathis v. Cannon, 276 Ga.16, 26 (2002)[ quoting Butterworth v. Butterworth, 227 Ga. 301, 303-304 (1971)]. 6. Using the above rules of statutory construction, it is clear that the Department intended that an applicant for a new home health agency must evidence an intent to obtain, and later strive for, full accreditation. This is the only logical construction because the Department will not permit an existing home health agency to expand later without documenting it has obtained full accreditation. 7. As noted in the findings of fact, United repeatedly stated in its application that it intended to become accredited. This is the same statement noted and relied upon by the Department in accepting the applications of Amedisys and Premier in its March 13,2007 Decision. See p. 9. No additional evidence of intent was mentioned in the Decision and no other 10 evidence of intent has been presented concerning either Amedisys or Premier. Nevertheless, their applications were accepted and they were allowed to undego the "tiebreaker" process. Decision, p.15 8. United argues that its statement of intent alone should qualify it as satisfying the rule for new home health agencies, as were the statements by Amedisys and Premier. Both the Department and Gentiva argue that United's statement of its intent was lessened or tarnished by lCARO's conditional status ofURC; therefore, United's statement of intent to become accredited should be discounted or overlooked, because United overstated its sister affiliates' status and extensively relied upon their records in its application. As noted above, both Gentiva and the Department would be correct if United applied as an expansion home health agency. 9. ApplYing the rule for "new" home health agencies, it appears that United has "evidenced" its intent to become accredited through its statements, and, in addition, the actions of its system operated by UHC. It is important to this decision that United did not rely upon merely the conditional accreditation of UHC. All throughout the period in question and up to the Department's Decision on March 13,2007, UHC was striving for 11 full accreditation. This fact is shown by ICARO's letter of March 1,2007 stating: "Your organization submitted an acceptable Evidence of Standards Compliance report, outlining corrective actions taken, and is currently awaiting an unannounced conditional follow up survey." Exhibit E, United's Motion To Remand. Rad URC not been seeking full accreditation it would not have received this letter from ICARD. The letter is, indeed, evidence of the actions taken by URC to obtain full accreditation, and it should have been considered as evidence of intent for a "new", as opposed to an "expanded", home health agency. Therefore, both the statement of intent by United and the actions of its parent in striving for full accreditation should have been considered in evaluating United's application for a CON. 10. The conclusion that the Department overlooked the statements by United and the actions of its parent URC during the review period does not affect or impact the Department's policy decisions or the deference due its interpretation of the CON statute and rules. 11. It appears this case is appropriate for remand, because United was precluded from being considered as an applicant under the tiebreaker rule that was applied to the other applications. It is more efficient and 12 economical for the Department to correct this error at this time before the case proceeds through the evidentiary hearing and appeal process. It is recommended that the Department consider all of the criteria of the tiebreaker rule, as well as any other applicable rules on remand. ORDER Based upon the above Findings of Fact and Conclusions of Law, the Motion to Remand by United is Granted, and the case is hereby Remanded to the Department for further consideration, review and findings consistent .., with this Order. It is further Ordered that the Department complete its review and issue its decision within 30 days of the entry of this Order. The record shall be kept open for sufficient time for the hearing officer to consider the action taken by the Department. SO ORDERED, this 14th day of July, 2007. tv~ t1.-#;- William C. Joy . Hearing Officer 13 ~" . STATE HEALTH PLANNING REVIEW BOARD STATE OF GEORGIA IN RE: AMEDISYS GEORGIA, LLC d/b/a AMEDISYS HOME HEALTH OF MACON PROJECT NO. GA 2006-130 INTREPID USA HEAL THCARE SERVICES,INC. PROJECT NO. GA 2006-131 UNITED HOME CARE OF SOUTHWEST GEORGIA, INC. PROJECT NO. GA 2006-132 DEPARTMENT OF COMMUNITY HEALTH'S STATEMENT OF UNDISPUTED MATERIAL FACTS COMES NOW the State of Georgia, the Department of Community Health (hereinafter "DCH" or "Department"), and submits its "Statement of Undisputed Material Facts" in the above referenced matter: 1. On September 14, 2006, the Department published a Hatching Review Cycle Notification for home health services identifying twelve (12) counties within SSDR 8 with unmet need for home health services. See Rules 111-2-2-.08(1) and 111-2-2-.32. In response to the notice, three (3) applicants filed applications proposing to serve some of the identified counties. See Decision,. Ex. A. 2. These applicants included: United, Amedisys, and Intrepid USA Healthcare Services (hereinafter "Intrepid"). See id. . 3. Amedisys proposed to expand its home health agency to serve the following ten (10) counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Stewart, Sumter, and Talbot. Amedisys already serves three (3) counties within SSDR 8: Taylor, Schley, and Muscogee. Intrepid proposed to establish a new home health agency to serve twelve (12) counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, and Taylor; and United proposed to establish a new home health agency to service serve twelve (12) counties: Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, and Taylor. See id. 4. Appellant United is a corporation that was formed on October 16, 2006, just one month prior to United's application in SSDR 8. See Correspondence to DCH from Neil L. Pruitt, Jr., attached hereto as Exhibit B. Appellant United is wholly owned by United Health Services of Georgia, Inc. which is itself wholly owned by United Health Services, Inc. (hereinafter "UHS") See United Application, p. 1.4, an excerpt of United's Application is attached hereto as Exhibit C. UHS also owns and operates four other home health agencies under the United Home Care or the UHC System. See id. 5. The four home health agencies and United operate as divisions of United Home Care. See id. at p. 10.8. During the application process, United represented to the Department that it intended to obtain accreditation by JCAHO and repeatedly stated that 2 . "UHC and all of its affiliated Home Health Agencies are fully accredited by [lCAHO]." See id. at pp. 10.8, 11.28. 6. In fact, UHC was not "fully accredited," but had obtained only "conditional accreditation." See Correspondence to Neil L. Pruitt from JCAHO dated August 16, 2006, attached hereto as Exhibit D; Correspondence to Neil L. Pruitt from JCAHO dated March 1,2007, attached hereto as Exhibit E. 7. According to JCAHO, a conditional accreditation is two levels below full accreditation and one level above preliminary denial. See JCAHO Guide p. 17, an excerpt of the JCAHO Guide is attached hereto as Exhibit F. UHC did not obtain full accreditation until May 21, 2007, two months after the Department's Decision. See Correspondence to Neil L. Pruitt from JCAHO, attached hereto as Exhibit G. 8. After reviewing the applications, the Department issued a decision on March 13, 2007 and awarded a CON to Amedisys to expand its home health services in SSDR 8. See Decision, Ex. A. 9. The Department denied the applications of Intrepid and United. See id. Only United has appealed the Department's decision. 10. 3 The Department denied United's application pursuant to Rules 111-2-2-.09(1)(c), 111-2-2-.09(1)( e); 111-2-2-.09(1 )(h), and 111-2-2-.09(1 )(m). Specifically, the Department found that United failed to provide adequate evidence of its intent to meet appropriate accreditation requirements of JCAHO because UHC was only conditionally accredited. See id. 11. Regarding the criteria for Rule 111-2-2-.32(3)(i), the Department stated: Accreditation by a recognized body such as JCAHO, CHAP and/or other appropriate accrediting agency indicates that an organization meets certain performance standards that enable it to provide quality patient care. As new home health applicants, Intrepid and UHC have stated their intent to seek accreditation from an appropriate accrediting organization, given approval. Intrepid submitted a copy of a letter addressed to CHAP regarding its intent to apply for accreditation as evidence. UHC provided documentation of the current accreditation status of United Home Care, Inc. a evidence of its ability to be compliant with this standard. However, the documentation provided by UHC reflects a conditional accreditation status for failure to meet select accreditation standards. Although UHC is proposing to establish a new agency in the service area, the inability of its existing operations to obtain full accreditation, as required by Rule 111-2- 2-.32(3)0)., make its own accreditation prospects dubious. Consequently, UHC failed to provide sufficient evidence of its ability to meet the appropriate accreditation requirements. . . . UHC does not meet the criteria of this rule. See id. at p. 8-9. 12. Because United failed to meet this criterion and the criteria of Rules 111-2-2- .32(3)(i); 111-2-2-.09(1)(e); and 111-2-2-.09(1)(h), United was not involved in the "tiebreaker" considerations of Rule 111-2-2-.08(1 )(h) and its application was denied outright. See id. at p. 17-18. 4 13. At the same time that the Department considered United's application for home health services in SSDR 8, the Department was also reviewing batched home health applications for SSDR 4, SSDR 5, SSDR 6, and SSDR 12. In each decision regarding these regions (all issued March 13, 2007), the Department denied United's applications for the same reasons it denied its application in this appeal. 14. For example, in the SSDR 5 Decision, the Department stated the following: Accreditation by a recognized body such as JCAHO or CHAP indicates that an organization meets certain performance standards that enable it to provide quality patient care. As applicants for new home health agencies, Camellia, Nightingale, Oconee, TriStar and United have stated their intent to seek accreditation from [JCAHO]. While United does not currently operated in SSDR 5, it currently operates several facilities across Georgia. In its most recent JCAHO accreditation review, United was awarded only "conditional accreditation", not full accreditation. On the JCAHO scale, "conditional accreditation" is only one step above "preliminary denial of accreditation." This performance calls into question United's ability to provide appropriate levels of quality and its ability to maintain full accreditation. United received a conditional accreditation from JCAHO. . . . United does not meet the criteria of this rule. See Exhibit 1. p. 10. United has also appealed the Department's decisions for SSDRs 4, 5,6, and 12. 15. After filing its appeal, on June 6, 2007, United filed a "Motion to Remand" in this case and all the other appeals, contending that this case should be remanded to the Department because the Department "erroneously determined that United did not satisfy the criteria of the applicable rule regarding accreditation requirements of [JCAHO]." 5 ~ This5\:> day of July, 2007. 40 Capitol Square, S.W. Atlanta, Georgia 30334-1300 Telephone: (404) 656-3202 Facsimile: (404) 656-0677 #446723 Respectfully submitted, THURBERT E. BAKER Attorney General 033887 6 / GEORGIA DEPARTMENT OF COMMUNITY HEALTH DMSION OF HEALm PLl.NNING EVAWATION FOR CERTIfICATE OF NEEO HOME HEALm BATCHING CYCLE SSDR8 PROJEcr No.: GA. 2006-130 AMEDISYS HOME HEALTH OF MACON PROJEcr No.: GA. 2006-131 INTREPID USA HEAlTHCARE SERVICES PRoJEcr No.: GA. 2006-132 UNITED HOME CARE OF SOUTHWEST GEORGIA BAacGROUNO Home Health services enable health care, medical care, sodal support services and other therapies to be delivered to IndMduals in their place of residence. Rule 111-2-2-.32())(aJdeflnes a home health agency as a private organization, or a subdivlslon of sudl an agency or organization, which is primarily engaged In providing care to Individuals who are under a written plan of care of a physician; on a visiting basis In the place of residence used as sudl Individual's home; part-time or Intenntttent nursing care provided by or under the supervision of a registered professional nurse; and one or more of the following services: physical therapy, oa::upatlonal therapy,. speech . therapy, medical-sodal services under the direction of a physidan, or part-time or intermittent services of a home health aide. PROJECT OVERVIEW The DMsion of Health Plannlng (Divislon) published a Batx:hing Review Cycle Notification for Home Health ServIces on September 14, 2006. This notification outlined the numerical need for home health services In applicable state service delivery regions. In addition, the notice outlined the following components of the review process: · Procedures for filing notices of Intent · Procedures for obtaining app\lcatlon forms · Data survey requIrements · RUng fee requIrements · Submission of CertIficate of Need (CON) applications · Procedures of the review cyde All parties Interested in applying under the numerical need provisions were required to file a written notice of Intent with the Division by 5:00 pm on October 16, 2006. Applicants were required to indude a defined geographic service area consistent with Rule 111-2-2-.32(2J(cJ In their intent notice. CON applicattons were due to the Department by 12:00 pm on November 13, 2006 in order to be induded in the current bat.ching cyde. The numeJical need for state service delivery region (SSDR) 8 authorized the consideration of applications for new and expanded home health services. In response, three (3) agencies submitted requests to the Georgia Deparbnent of Community Health, Division of Health Planning for issuance of Certificates of Need for home health services In SSDR 8. The applicants are described as follows: ,'~ EXHIBtfn If ..e' 'i Amedisys Georala, UC d/b/a Amedisys Home Health of Macon Amedisys Home Health of Macon rAmedisysj has requested a certlfk:ate of Need to expand Its home health agency Into the fol1owlng Counties: Chattahoochee, Oay, Harris, Macon, Marion, Qultman, Randolph, stEwart, Sumter and Talbot. These Counties show a need for 621 patients. Amedisys currently serves Taylor, Schley and Muscogee counties In SSOR 8. The total estimated mst for the proposed project Is $125,000. Intrepid USA HeaJthcare Services, Inc Intrepid USA Healthcare Services, Ine ("Intrepldj has requested a Certificate of Need to establish a new home health agency to serve the following counties: Olattahoochee, Oay, Harris, Macon, Marion, Qultman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project has a total estimated cost of $70,000. United Home Care of South West Georala, Inc. United Home Care of South West Georgia, Ine ("UHC') has requested a Cerl:ificate of Need to establish a new home health agency to service the following countles~. Olattahoochee, Oay, Hams, Macon, Marion, Qultman, Randolph, Schley, 5rewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The project: has a total estimated cost of $228,363. . PROJECT EVAWAnON The proposals submitted by Amedisys, Intrepid and UHC were reviewed according to the relevant CertIficate of Need rules outlined In the General RevIew Considerations and Home Health Services Addendum of the Georgia State Health Plan. The following are the review findings for each of these rules. General Review Considerations The population residing In the area serve4 or tD be 5l9I'Ve4 by the new Institutional health service has a need for such servfcx]s. The Home Health ServIces Component Plan establishes an objed:ive need methodology for home health services based on the utilization of services by different age cohorts. Projected future need 15 determined by an established rate for a defined population cohort. Projected service capacity is then subtracted from the projected need to determine unmet need. This need methodology Is outlined In Rule 111-2-2-.32(3J{aJof the state CertIficate of Need law. Rule 111-2-2-.09(1J{b): The Division of Health Planning issued a Batchlng Review Cycle NotifICation for Home Health Services on September 14, 2006 In compliance with Rule 111-2-2-.08(1J. In this notification, the Division identified a net numerical unmet need of 515 patients in SSDR 8. The sum of only those counties with unmet need In SSDR 8 Is 702. The Department authorized the submission of applications for new and expanded home health services in the selVice delivery region based on the submission criteria outlined In Rule 111-2-2-.32(3){b). Of the sixteen counties In SSDR 8, twelve counties have an unmet need for home health services. The table below lists SSDR 8 counties and their corresponding numerical need as detennlned by the Division of Health Planning. SSDR 8 Home Health Batchlng Evaluation of ProJects March 13, 2007 Page 2 I ;' , ExhIbit One. Need for Home Health ServIces In SSOR 8 Bv Countv. .\ :'~':."i::l.\':'\'~ ~:::\;::Unm~t Nee(Uor flome Health SerYlces .' .... '... . " ': :.: ...: . ; .:::::'. :..:..:::.:.::.;:;;...... :.:.:~::.:;-:i~:~:;.:.:::.::::~.;: ~'::";SSDR 8 ~:'::" . ". ' : ,... .:.., ': . '.. '.. COunty Need Olaltahoochee 94 Cav ,58 Harris 204 . . Macon 58 Marion 33 Oultman 21 Randoloh 27 Schlev 3S Stewart 12 Sumter 75 Talbot 39 Tavlor 39 Total 702 5wI1:!:;. DIvIsion of Health PlannIng Ba/r:hJng Review C)t:k Notification SepIsnber 14, 2006. Based on the numerical unmet need of 515, the Department has authorized new and expanded home health services In SSOR 8. All applicants have proposed to meet the threshold need for new or expanded home health servlces by Year 2ln their pro forma. All applicants meet the aiteria of this rule individuany. Home Health'Addendum Rule 111-2-2-.32(3X~); The need for a new or expanded home health agency shan be determined through application of a numerical need method and an assessment of the projected number of patienfs to be served by existing agencies. 1. The numerical need for a new or expanded home health agency In any planning area In the hotfzon year shall be based on the estimated number of annual home health patients withIn each planning area as determined by a population-based fonnula which Is a sum of the foUowlng for each county within the health plannIng area: (i) a ratio of 4 patients per 1,000 projected horizon year resident population age 17 and younger; (ii) a ratio of 5 patients per 1,000 projected horizon year resIdent population age 18 through 64; (iii) a ratio of 4S patients per 1,000 projected horizon year resident population age 65 through 79; and (iv) a ratio of 185 patients per 1,000 projected horizon year resident population age 80 and older. 2. The net numerical unmet need for home health serviCes shan be detennined by subtractlng the projected number of patients for the cunent calendar year from the projected need for services as calculated in (3)(a)(l). The projected number of patIents for the current calendar year Is determined by multiplying the number of patients having received SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 3 , . services in each county, as reported In the most recent survey year, by the county population change radar. The county population change radar Is the perrent change In total population between the most recent survey year and the aJrrent calendar year. N:. discussed In the evaluation of Rule 111-2-2-.09f1J(b)r the Division has detennlned a net numerical unmet need of 515 patients and an unmet need of 702 patients in SSDR 8 based.on the need methodology outlined In this Rule. Intrepid and UHC have requested to establish new agencies and Amedisys has requested to expand their service area. All applicants have proposed to meet the requested threshold need by year two of implementation for the counties for which they have applied. Need 1J UHC ChaUahoochee 94 94 94 Cay 58 58 58 Harris 204 204 204 Maoon 58 58 58 Marion 33 33 33 Qultrnan 21 21 21 Randolph 27 27 27 Schley 3S 3S 35 StEwart 12. 12 12 Sumter 75 75 75 Talbot 39 39 39 Taytor 46 46 46 Total 702 702 702 All applicants IndividuaHy meet the afterIa of this role. Rule 111-2-2-.32{3J{bJ: 1. the DMslon shall accept applications for review as enumerated below: (/) If the net numerical unmet need in a given planning area is 250 patients or more, the Department shall authorize the submission of applications for an expanded home health agency; or (0) If the numerical unmet need In a given planning area is 500 patients or more, the Department shall authorize the submission of applications for a new home health agency as well as an expanded home health agency. 2. An applicant must propose to provide service only within a geographiC service area comprised of a county or group of counties, each of which reflects a numerical unmet need, and contained within the given plannIng area for which the Department has authorized the submission of applications, SSDR 8 Home Health Batchlng Evaluation of Projects March 13. 2007 Page 4 / , , , . 3. The Department shall only approve app/iaJtIons In which the appUcanthas applied tD serve all of the unmet numerical need In anyone county In whIch need Is projected. The need wtthln counties shall not be dMded or shared between any two or more applicants. As discussed in the evaluation of Rule 111-2-2-.09(Q). the Department has determined that there Is a need for the proposed project. Intrepid and UHC have requested to establlsb new, home health agencies, Amedisys has requested to expand Its existing servkE area Into counties reflecting need. All applicants meet the aiteria of this rule. Rule 111-2-2-.32(3){c): The DMslon may authorize an exception to Rule 111-2-2-.32(3'J{aJ If: 1. the applicant for a new or expanded home health agency can show that there Is Umlted aa:ess In the proposed geographiC service area for special groups such as; but not IirnIred to, medically fragIle chJIdren, newborns and their mothets, and HIV/AlDS patients. For purposes of this exception, an applicant shall be required tD document; using population, service, spedal needs and/or disease InckJence rates, a projected need for services In the planning area of at /east 200 patients withIn a defined geographic service area. A sucr::essful app/iaJnt applying under this sed:Ion wIU be restridJ!!d to serving the spedaI group or groups IdentiIied In the application within the county or a>untles stipulatEd In the application; or 2. a particular aJUnty Is served by no more than two (2) home health agendes and less than one percent of the county's population has received home health ~ or the agencies have demonstrated a fa/lure tD adequately serve MedIcaid patients as evideJ1tm by a level of service tD such lndMduals that Is less than the statewlde average, wIth/n each of the past two years as reported on the Annual Home Health Servlces survey. For purposes of this exreption, an applicant must already be approved tD provide service In a amtIguous aJU11ly or be approved tD provlde servICe In a a>Unty which Is no further than 1S mIles from the county authorized through the exception. In a/I other aspects of the appflCiJtIon process, the appUcant shall be required tD comply with provisions applicable tD expan~ home health agendes. None of the applicants Induded In the current batchlng review cyde for SSDR 8 has applied for a Home Health Services exception as defined In this Rule. The aiteria of this rule are not applicable to the proposed projects. Rule 111-2-2-.32f3J(dJ; An applicant for a new or expanded home health agency shall provide a community linki1ge plan which demonstrates factors such as, but not limited to, referral arrangements with appropriate services of the health care system and working agreements with other related community services assuring a>ntlnulty of care focuslng on a>ordinated, Integrated systems which promote continuity rather than SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 6 , I"~ , . aa.rte, ep/socflC care. Working agreements with other related community serviceS may Indude the abUlty to streamline referrals to other appropriate setVIces and to partfdpate In the development of aDSS-rontinuum care plans with other providers. loo-easlng concern with continuity of care makes It Imperative that attention be focused on coordinated care. Among factors Influencing continuity of care Is the expectation that,hlgher acuity care will be provided by home health agencies. This prospect reinforces the necessity for a community linkage plan that will allow a seamless transition of high aOJity patients to an appropriate level of care. k; such, the Department requested In the Sixty Day meeting that all applicants in this competitive review process provide a detailed plan and discussion of efforts made to foster community linkages. AmecfJSYS Amedlsys stated that Its organization has developed working agreements and refenal arrangements with other providers In the communities in which It serves. The applicant provided documentation of a recent a<Xlulsltion of a therapy staffing company that Is expected to serve Amedisys on a company wide basis. Additionally, a personnel contract agreement for physical therapy services was submitted as evidence of the applicant's aJrrent ability to readily obtain these services. letters of support were also submitted from practitioners, assisted IMng faaTaties and org~nlzat:lons that typtcally serve populations with the greatest potential for needing home health care within the servlce area. Furthermore, the applicant noted that Its organization holds positions, which relate to the ongoing development of community linkages. These positions are requIred to work with all appropriate staff and other members In the health care community to promote quality healthcare services, as weD as to plan and execute special events, which serve to advance staff, patient, and community relations. The Department reviewed the trend In patient volume at Amedtsys over the past two years for a sense of the effectiveness of Its mmmunlty linkage relationshIps. Between 2003 and 200S the total patient visits from Its SSOR 8 service area munties (Schiel and Taylor) lnaeased from 90 to 295. IntreD/d Intrepid provided a phased framework for developtng community Unkages In the proposed service area including a detailed Implementation plan. Letters of support were submitted from practitioners, and various organizations. Intrepid also provided a detailed log of mntacts made with various providers and the outcomes as evldence of its Intent to estabrlSh reclprocal referral agreements. UHC k; a part of a large and vertically Integrated health system, UHC doaJmented Its aa:ess to a full oontinuum of healthcare services as evidence of Its ability to ensure continuity of care. The applicant provided mples of its alent Transfer Agreements with each of the existing Intra-network fadlities and agencies that have been established. Arguably, this intra-network working relationship would offer great assurance of UHC's ability to develop a streamlined, cross continuum refenal base. UHC provided a Community Unkage Plan outlining the local organizations and practitioners It has mntacted to develop linkages in the service area. The plan provided a framework for inaeasing public awareness of its services, means of access and to encourage utilization. Letters of support were provided. The Deparbnent finds that community linkage plans and efforts presented by all applicants meet the requirements to develop continuity of care within their respective service areas and All applicants minimally meet the criteria of this role. 1 Schley County was licensed in September 2004 SSDR a Home Health Batchlng Evaluation of Projects March 13. 2007 Page 6 , . Rule 111-2-2-.32(3)(e); An appDcant for a new or expanded home health agenc.y shall provide a written statement of Its Intent to comply with all appropriate licensure requirements and operational procedures required by the Office of Regulatory Services of the Georgia Department of Human Resourr::es. Home Health fadlities In Georgia are required to meet minimum operational standard,s In order tD ensure that citizens receive a quality level of service. These standards are defined In the licensure rules and operational procedures established by the Georgia Department of Human Resources, Office of Regulatory Services. All applicants In the current bal:ching review cycle for SSDR 8 have stated their Intent to comply with appropriate licensure requirements and operational procedures. All applicants meet the atteria of this rule Rule 111-2.2-.32(3)(f): An applicant for a new or expanded home health agency or agen<.y(les) owned and/or operated by the applicant or Its parent organ/zafion shall have no history of uf1COl'ff!iclBd or repeated amdltlonallevel vfoIations or unrorrec!ed standard defidendes as Identified by Ucensure Inspections or equivalent defidencies as noted from Medicare or Med"1CB1d aualts. All applicants affinn that neither they, nor their parent organlzatton have a history of uncorrected or repeated c:on<fltlonal level defidendes or uncorrected standard deficiencies as Identified by licensure Inspections or equivalent defidendes as noted from Medicare or Medicaid audits. Applicants provided documentation from the Department of Human Resources, which verifies that none have uncorrected regulatory deficiencies. Rule 111-2-2-.32(3){q): All applicants meet the aIterIa of this rule. An applicant for a new or expanded home health agency or agency(1es) owned and/or operated by the appUcant or Its parent . OlfIan/zation shall have no previous convidion of Medicaid or MeOICBre fraud. . All apprlCants have afflrmed that neither they nor their parent organizations have previous c:onvld:lons of Medicaid or Medicare fraud. Rule 111-2-2-.32{3)(h); All applicants meet the atterIa of this rule. An applicant for a new or expanded home health agency shall provide a written plan which demonstrates the Intent and ability to recruit, hire and retaIn the appropriate numbers of qualified personnel to meet the requirements of the services proposed to be provided and that such personnel are available in the proposed geographic service area. A new or expanded home health agency should have in place a plan, which specifies measurable strategies for staff selection, training and retention. In order to promote Improved outcomes for consumers, providers must focus on staff. The chart below details the projected full-time equivalent (FfE) staffing needs by Year 2 of project implementation. SSDR 8 Home Health Batchlng EvaluatIon of Projects March 13. 2007 Page 7 / . .I , . Exhibit Three. Projected Staffing by Year Two 40 30 20 10 o Am edis ys * 19 35 4 70 Intre pid 3396 469 UHC 14 39 4.23 .AII Staff m Nurses ~ Home Health BatchIng Applications, SSDR 8 ~ on projected InctementaI staffing needs for the proposed expans10n Otganizational total staff to nurse 1800 Is 74 to 15.9 Amecf\5YS projects 1,543 inaemental visits per nurse by year two of implementation, or approximately S.g2 visits per nurse per day. Intrepld and UHC project 1300 visits annually or 4 visits per nurse daOy and 1153 visits annually or 4.4 visits per nurse dally, respectively. All applicants have developed reaultment and retention strategies for both fuU time and contract staff. The applicants intend to reault the majority of staff from local resources, Including the pool of .part-time and non-working nursing professionals, community service agencies, medical equipment finns, other healthcare providers, and area coUeges. In addition, applicants will ublize networking relationships established through their parent organizations to recruit staff. Retention efforts wlII focus primarily on quality Improvement and continuing educatlon/trainlng. All applicants meet the aiterla of this rule. An applicant for a new home health agency shall provldeevfdenre of the InIBnt to meet the appropriate aa:redltatlon requIrements of the Joint Commission for Aa:red'JtiJtion of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc.. (CHAP), and/or other appropriate accrediting agency. Accreditation by a recognized body such as JCAHO, mAP and/or other appropriate accrediting agency Indicates that an organization meets certain performance standards that enable It to provide quality patient care. As new home health applicants, Intrepid and UHC have stated their intent to seek accreditation from an appropriate accrediting organization, given apProval. Intrepidsubrnitted a copy of a letter addressed to CHAP regarding its Intent to apply for accreditation as evidence~ UH~ provided documentation of the current accreditation status of United Home Care, Inc. as evidence of its ability to be compliant with this standard. However, the documentation provided by UHC reflects a conditional aa:reditation status for failure to meet select accreditation standards. Although UHC Is proposing to establish a new agency in the service area, the Inability of its existing operations to obtain full accreditation, as required by Rule 111-2-2-.32(3JaJ.. makes its own accreditation prospects dubious. Consequently, UHC failed to provide sufficient evidence of its ability to meet the appropriate accreclitation requirements. Rule 111-2-2-.32(3)(1): 2 Based on an average of 260 days per year, excluding holidays and other non-work days SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 8 ,( , . Intrepid meets the afteria of this rule. UHC does not meet the atterIa of this rule. This rule is not applicable to Amedisys. An applicant for an expanded home health agency shaff provide documentation that they are fuRy accredited by t/J.e JoInt CommJssIon for Accrecfttafion of Health Care Organizations (JCAHO), the Community Health Accreditation Program, Inc. (Q-fAP), and/or other appropriate accrediting agency. As noted In the evaluation of the previous rule, accreditation by a recognized body Indicates that an organization meets certain perfonnance standards that enable It to provide quality patient care. As the two major accrCditatlon bodies, JCAHO and otAP are recognized nationally for standards that reflect high-level performance expectations. In order to ensure that such a level of quality exists In home health services that are awarded a CON, accreditation by such a body Is required for the expansion of existing home health agencies. Rule 111-2-2-.32(3)(iJ: Amedisys submitted documentation of their accreditation from JCAHO and provided documentation of its efforts toward re-acx:reditation. Amet:f/5YS meets the aiteria of this rule. This rule Is not applicable to IntrepId and UHC An applicant for a new or expanded home health agency shall provide Its existing or proposed plan for a axnprehens/ve quality Improvement program. The Home Health Services Component Plan states that providers should have quality Improvement programs consisting of outmmes data and up-to-date industry benchmarks that address patient outoomes, consumer satisfaction and demand, and patient/oonsumer rights. Rule 111-2-2-.32(3)(k): All applicants provided adequate plans for comprehensive quality improvement programs consiSting of an integrated and systematic approach to monitoring, evaluating and reporting quality of patient services. All applicants meet the aiteria of this rule. Rule 111-2-2-.32(3XI): An applicant for a new or expanded home health agency shaff assure aa::ess to services to IndMduals unable to pay and to alllnd"1VIduafs regardless of payment ~urce or drcumsf1!Jnces by: (i) providing evidence of written administrative policies that prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or ability to pay; (ii) providing a written commitment that services for Indigent and dJarity patients will be offered at a standard which meets or exceeds three percent of annuat adjusted gross revenues for the home health agency or, in the case of an applicant providing other health services, the applicant may request that the Division allow the commitment for SSDR 8 Home Health Batchlng March 13, 2007 Evaluation of Projects Page 9 ,I , . servia!s to Indigent and charfty patients to be applied to the entire facility; (//7) provkfll1g documentation of the demonstrated performance of the applicant, and any fac/(/ty In Georgia owned or operated by the applicant's parent organization, of providing services to Medicare, MedicaId, and Indigent and charily patients; (iv) provldlng a written commitment to participate In the Medicare, Medicaid and PeachCare programs; and (v) providing a written commitment to partidpate in any other state health benefits Insurance programs for which the home health service Is ef1{Jlble. Rule 111-2-2-.09(1)(g): The new Institutional health service proposed Is reasonably Dnandally and physically aa:assIble to the residents of the proposed servlce area and the appfJcant assures there will be no d"ISCffm/natJon by virtue of race, age, 5e)Cf handicap, CDIor, aeed, or ethnic affiliation. The Department is required to evaluate the extent to which applicants are finandany and physically aa:essible to the residents of their service area. ThIs evaluation Indudes an assessment of plans for the provision of servicEs to low Income and medically indigent patients and Medicare/Medicaid recipients. In addition, the Department analyzes applicants In terms of mmpllance with existing Indigent and charity caremmmitments, if any; Medicare and Medicaid utirlZatlon levels in mmparison to planning area and statewide levels; and cOmmunity outreach efforts. The Department utilizes a standard of three {3} percent of adjusted gross revenues as an acceptable level of indigent and charity care. All applicants provided mpies of administrative poRdes designed to prohibit the exclusion of services to any patient on the basis of age, disability, gender, race, or ablTrt.y to pay. Additionally, all applicants stated their Intent to mntinue to participate In the Medicare and Medicaid programs and stipulated their mmmltment to participate In any other state health benefit Insurance programs for which home health services are eligible. In addition to the review of administrative polices, the Department evaluates the level of services to Medicare and Medicaid patients. Ameclisys Home Health of Macon is proposing to expand its two munly service area In SSDR 8; the Mamn agency has an established record of petfonnance in the home health industry In other service areas In the state of Georgia. While Its service area mnsists primarily of SSDR 6 counties, 94.3 percent of total visits for Amedisys were Medicare and 2.0 percent of visits were Medicaid. The two active SSDR 8 servtce area counties are Induded In these figures. The Department also reviewed the mrporate-w1de performance of Amedisys, Inc. to evaluate its historical Medicare and Medicaid ubllzatlon. In 2005, Amedisys, Inc., which mnslsts of thirteen (13) agencies statewide had 91.3 percent Medicare visits, while Medicaid accounted for 2.8 percent of visits. Similarly, the Department reviewed the Medicare and Medicaid utilization for agendes affiliated with Intrepid. Of the three agencies in operation in 2005, 82.4 percent of total visits were Medicare and 5.5 percent Medicaid. UHS proposes to establish a new agency In SSDR 8, however, in 2005, 90.4 percent of the total visits mnducted by its affiliate UHS-Pruitt were Medicare patients, while 2.7 percent of visits were Medicaid patients. SSDR 8 Home Health Batchlng Evaluation of Projects March 13. 2007 Page 10 .f . . Medicare and Medicaid utilization for SSDR 8 was 83.0 pen::ent and 5.6 percent of visits respectively. In the state of Georgia, Medicare accounted for 81.3 percent of total home health visits while there was a reported 6.4 percent Medicaid visits. Exhibit Four. 2005 Medicare and MeOlCilkl Utilization 100 80 60 40 20 . .liedica" 111M ediclld h edisJI 813 2.1 latrepid 824 5.5 UHS.p l1Iitt 104 ..... .... .... ...--...... ..- 21 Source:2005 Annual Home Health SUrvev Data 18t1ects the hJstoricaI pedonnanae of affiliated agencies. In evaluating finandal aa::esslbllity, the Department evaluates the applica~s level of Indigent and charity care commlbnent for the previous three (3) years. Historically the provision of Indigent and charity care by home health agendes has been less than the mandatory 3 percent mmmibnent. The extent of cnverage and reimbursement through Medicare and Medicaid programs and poor patient tracking and categorization have arguably been deemed contributing fadDrs to the low ind"tgent and charity care perfonnance In home health agenqes. As sudl, all applicants were asked to submit a plan for providtng the oommltted level of Indigent and charily care services at the Sixty Day meeting. Amedisys ~ from the Division of Health Planning reftecI:s that the Indigent and charity care performance of Amedisys has mirrored that of most other home health agencies, aa:ounting for only 0.04 percent of Its adjusted gross revenues In 2004 and O~Ol pen:ent In 2003. However, In 2005, Amedisys was one of only two agencies in SSDR 8 to meet Its 3 percent (X)ffimltrnent though the direct provision of care. Amedisys argues that Its historically low indigent and charity performance was largely due to poor accounting of indigent and charity care patients. The applicant Identified cases where patients who should have been categorized as indigent or charity patients were Included In bad debt aa:ounts. Amedisys ascertains that Improving Its aa:ounting and tracking system will improve Its record of Indigent and charity care perfonnance for all of its affiliated agencies. Amedlsys revised and Implemented a new Indigent and Charity Care Policy. Amedisys creditS this policy and other operational changes with Its ability to meet its indigent and charity care commitment directly. Additionally, there has been a reduction in the shortfall amounts for the affiliated agendes. In 2003, Amedlsys had one indigent and charity care commItment which resulted in a shortfall of $17,029. By 2004 the shortfall amount skyrocketed to $291,581 for three active commitments. For 2005, the shortfall amount leveled out at $20,704 for six active commitments. The reduction in shortfall payments is due to concerted efforts by Amedlsys. to locate indigent and charity patients and to appropriately document the care provided. Amedlsys will target and promote itS services to providers serving the indigent and charity care population to ensure that it meets Its commitments in the future. These efforts by Amedisys are outlined in a restated comprehensive Indigent and Charity Care policy. SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 11 / , , , Intrepid Intrepid dIscussed the unpredictabllity of the payor dass of patients referred for home health services and the difficulty that exists in attracting Indigent and charity care patients In a service area supported by a large hospital based home health agency, as is SSDR 8. Nonetheless, Intrepid renders its commitment of at least 3 percent of its AGR to serve thls group. Intrepld's plan to meet this goal consists largely of organizational initiatives through the deve10pment of special committees to develop methods and processes of Identifying and servicing these patients . Additionally, Intreplt1 asserts that its marketing efforts In the area will Include a statement of Its cornmltment to providing care to Indigent and charity patients, The agency will also Incorporate thls commitment Into staff functions and training to ensure that It Is properly promoted at all points of access to patients. Despite these planned measures, affiliared agencies nave-provided Utile to no Indigent care In other service regions. In SSDRs 10, 11 and 12, Intrepid provided a dismal .01 percent, 0 percent and 0.25 percent, respectively In 2005. ~ UHC plans to Implement a comprehensive Indigent and charity care plan. UHC plans to Inform patients and consumers at large about the availability of Its program through the admissions process and marketing strategies through the use of informational flyers. As evidence of its commitment to serve the Indigent, UHC's Indigent and charity care plan will be Implemented on a corporate-wide basis. UHC projects that revisions made to its indigent and charity care plan will improve Its historical provision of care to thts underserved population. Between 2003 and 2005, UHC agencies have provided very limited Indigent and charity care. During this time, none of UHC's agencies met their commitments through the direct provision of care. Instead UHC paId an average of $122,385 In shortfall payments to fulml its obligations. Although, the provision of indigent and charity care by home health agencies has been less than the mandatory three percent (3%) commitment, the Department continues to monitor the performance of agencies, which desire expansion or to establish a new agency. The Department preference Is that home health agencies provide the committed level of indigent and charity care servtces, which Is the crux of the commItment, versus paying timely monetary shortfalls. In summary, the Department finds that Amedisys has demonstrated Its ability to provide a larger portion of Indigent and charity care to Its ament patient population, thus, Amedtsys Is found to be financially and physically a<msslble to the population it proposes to serve. COnversely, as Intrepid and UHC have hlstoricaUy provided limited Indigent and charity care, the Department found that Intrepid and UHC are not as finandally and physicaUy accessible as Amedisys. The Department notes that It will continue to monitor the lnolgent and charity care perfonnance of Intrepid and UHC. All applicants minimally meet the alteria of these rules. Rule 111-2-2-.32(3Jm: An applicant for a new or expanded home health agency shall demonstrate that their proposed charges compare favorably with the charges of existing home health agencies In the same geographic service area. All applicants have projected that the majority of their services will be rendered to Medicare patients. Given the fIXed rate prospective payment system that has been implemented for Medicare reimbursement, all agendes in the service area will be paid at the same. rate regardless of their charge structure. SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 12 ,. , ' , . Exhibit FIVe. Projecmd Avernge Olarge by Year Two of Implementation.. $170 $160 $150 $140 $130 $120 A m e d is y s UHC SSDR 8 Intrepid SOUtee: CON Home Health ADotications.GA2006-130. GA2006-131. GA2006-132 and 2005 Home Health Aaencv Survey Rule 111-2-2-.32(3)(nJ: All applicants meet the aiterfa of this rule. An applicant for a new or expanded home health agency shall doaunent an agreement to provide DMslon requested Information and stat:Ist:Ical data reIat1!!d to the operation and provision of home health servIres and to report that data to the DMs/on In the time /tame and fonnat requested by the DMs/on. Uniform data Is important to assess changing patterns and projed:ed service needs relevant tD the provision of home health services. Flirthennore, data enables.the Division tD analyze quality, patient outcomes, and axnmunlty benefit. A (\ew or expanded home health agency must provide the Division with requested Information and statistical data related to the operation and provision of home health 5eI'VIoos. All appllcants have stated their intent to provlde information and data related tD their home health services in the required time frame and fonnat requested by the Division. Additionally, UHS- Pruitt stated its wiUingness to continue to assist the Department in various initiatives to examine the key issues affecting the delivery of long term care services. All applicants meet the aIterfa of this rule. The Department may authorize an existing home health agency tv transfer one county or several counties to another exJstIng home health agency without either agency being required to apply for a new or expanded certificate of need, provided the following CDnditiOns are met: Rule 111-2-2-.32(3}{oJ: (I) the two agencies agree to the transfer and submit such agreement and a joint request to transfer in writing to the department at least thirty (30) days prior to the proposed effective date of the transfer, (ii) the two agencies document within the written request that the. transfer would result in increased and Improved services for the residents of the county or counties including Medicare and Medicaid patients; (Iii) the agency to which the county or counties are being transferred currently offers services in at least one contiguous county or within SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 13 " .~ , ' , . the sl:iJte service delivery reglon(s) In which county or counties are IoaJtedi and (iv) the too agencies are In compliance with all other requirements of these rules; such compliance to be evaluated with the written transfer request . No such transfer shall become effed:ive without written approval from the department The proposed projects do not involve the consolidation of services through aCXIuisition of an existing agency, transfer of counties between agencies or the merger of agencies. The aiterla of this rule are not applicable to the proposed project General Review Conslderatfons continued Rule 111-2-2-.09(1)(C): Existing alternatives for providing services In the service area the same as the new Institufional health service proposed are neither wrrently available, bnplemented, simHarfy utilized, nor capable of providing a less costIyaJtemative, or no Cerfjficate-of Need to provide such alternative services has been Issued by the Department and Is wtrenf:ly valid. Aa::ording to Information compiled from the 2005 Annual Home Health Survey, there were seventeen3 (17) home health providers serving SSDR 8. These agencies provided 112,251 visits to 6,048 patients. Despite the exlstence of these agencies and the level of home health care servlces provided, the DMslon has determlned an unmet need for home health serviCeS In twelve (12) counties of SSDR 8 based on the ~ methodology outlined In Rule 111-.2-2-.32(3J{a). Given that the Deparbnent has identified an unmet need for home health services, there are no existing alternatives to the proposals submitted by the applicants. All appUcants meet the aiteria of this rule. Rule 111-2-2-.09(1)(d': The project can be adequately financed and Is, In the Intermediate and long-term, finandaUy feasible. Amedi$J'S Amedisys estimates a total project cost of $125,000. The proposed project will be financed through cash reserves. John Giblin, Ollef Executive Officer of Amedisys, lne, verified the availability of funding. Additionally, the applicant submitted financial statements to further substantiate fund availability. Amedlsys anticipates that the project will be Implemented In July 2007. By Year 2, the applicant projects net income of $386,207. The applicant's pro forma reflects 621 additional patients served by Year 2 of the expansion project for a total of 2,112 patients. Intreoid Intrepid estimates a total project cost of $70,000. The proposed project will be financed. through unrestricted cash on hand. Gregory Von Arx, Chief Rnandal Officer of Intrepid Hea\thcare USA, verified the availability of funds. Additionally, the applicant submitted un-audited financial statements 3 Access Home Health in Muscogee County, closed on September 7,2005. SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 14 .. -., , . , . for Intrepid USA Healthcare Services and Intrepid USA Ine. Financials for Intrepid USA Healthcare Services reflect a net loss by the end of fiscal year 2006. Financial statements for Intrepid USA, Inc. reflect a profit during the same period that could adequately fund the project. The appncant stipulates that all home health agencies do business as Intrepid USA Healthcare Services. The applicant antldpates that the project will be Implemented by July 2007. By year 2, the appUcant projects to selVe 702 patients. UHC UHC estimates a total project cost of $228,363. The proposed expansion will be financed thro,ugh unrestricted reserves on hand. The applicant submItted its most recent financial statement and a letter from Chief Executive Officer, Greg Wren, to verify the availability of funding. UHC antidpates that the project will be lmplemented no tater than July 2007. The pro fonna projections for Year 2 Indicate a net income of $89,713 and service to 702 patients. The proposals submitted by Amedisys, Intrepid and UHC are adequately financ:ed and found to be reasonably financially feasible, based on the assumptions provided. All applicants meet the afterIa of this rule. Rule 111-2-2-.0!J(1)(e): The effects of the new Institutional health service on payors for health services, Including governmental payors, are not unreasonable. As disaJssed in the evaluation of Rule 111-2-2-.32(3)(m). the fixed rate prospec:tlve payment system of Medicare ensures that all home health providers in a geographic service area are reImbursed for their services at the same amount, regardless of charges. Therefore, the services proposed by the applicants In the batchlng review cyde for SSDR 8 are not expected to have an unreasonable effect on payors for health services. In fact, they should alleviate some of the finandal oonstralnts for payors of health services because of the mandatory 3% indigent and charity care oomml1ment. However, since the Department found that the project proposed by UHC has not met the requirements of Rule 111-2- 2-.32(~)(f). the project proposed by UHC Is not found to have reasonable effects on payers for health services in the proposed service area. The institutional health selVlce proposed by Amed"JSyS and Intrepid may serve to rnalce home health services more financially accessible to a variety of payors. Amedisys and Intrepfd meet the aitsia of this rute.. UHC does not meet the'atreria of this rule. Rule 111-2-2-.09(1J(O: The costs and methods of a proposed construction projed:, Including the costs and methods of energy provisIon and conservation, are reasonable and adequate for quality health care., The nature of home health services requires that the majority of care be provided in the homes of patients. Consequently, none of the proposed projects involves construction to implement. All the applicants either have existing administrative offices or have proposed leasing office space upon approval. All of the applicants have provided verification of the availablllty of the proposed sites for their administrative offices and have stated that these sites are properly zoned for the administrative functions of a home health service. The aiteria of this rule are not applicable to the proposed projects. Rule 111-2-2-.09(1J(hJ: The proposed new institutional health service has a positive relationship to the existing health care delivery system In the service area. SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 15 ., . .--; . . Applications for new or expanded home health services were filed In response to a need identified by the Department, through a batching notice. The proposals as submitted by the applicants are Intended to address this ldentifted need. Home health care Is a very specific, specialized type of home care that focuses on a specific type of patient, those who are transltionlng out of an acute car setling or those who are unable to care for themselves. As such, the lack. of available home health care services could potentially lead to greater utilizatiOn of more costly long tenn care alternatives, such as nursing home care, which would ultimately lead to an increase In health care cosj:s In 9,eneral. New Institutional health selVices that fundamentally meet the rule aiteria can be reasonably expected to have a positive relationship to the.exlsting health care delivery system in the selVice area. However, since the Department detennined that UHC faDed to meet the criteria of Rule 111-2-2-.32(3J(jJ, It will not have a positive effect on the existing health care delivery system. In fact, the limitation of care to the indigent and the potential Inability to fully meet quality of care standards may be a detrimental hIndrance to the effective delivery of home health care services In the region. AmeGJSyS and Intrepid meet the afterIa of this rule. UHC does not meet the aiteria of the rule Rule 111-2-2-.09(lJ(j): The proposed new Institutional health service provides, or would provide, a substantial portion of Its services to inOlVIduals not residing In Its defined servlce area or the adjacent service area. 7111s aiterion Is not appUcable to home health projects.. Rule 111-2-2-.09(1J{kJ: The proposed new Institutional health service conducts biomedical or behavioral research projects or a new service development, whIch Is designed to meet a natlona~ reglona~ or a statewide need. The applicants will not conduct biomedical or behavioral research projects or develop any new service. The aiterion of this rule Is not applicable to the proposed project. Rule 111-2-2-.09(1J{1J: 711e proposed new Institutional health servlce meets the dinlcal needs of health professional programs which request assistance.. All applicants IncrlC81E! their Intent to provide assistance to health professional programs as requested. Amedlsys Indicated Its provision of dassroom Instructiori at nursing an.ct other professional schools in the Macon area and Its Intent to expand such efforts In SSDR 8. Amedisys also serves as a clinical rotation site for nursing schools at an area university. likewise, UHC discussed its organizational wide commitment to assisting health professional programs meet their dinical needs through the provision of scholarships and planned Implementation of a local preceptor program. All applicants meet the criteria of this rule. Rule 111-2-2-.09f1J(mJ; me proposed new institutional health service fosters improvements or innovations In the finandng 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. Home health care by its very nature is a more cost effective alternative in healthcare as is evidenced by the proposed costs and charges. Amedlsys SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 16 ~ .0' , . , . Amedisys indicated Its rea>gnltion by a national organization for Its Disease Stare Management programs for maximIzIng the recovery and functionality of Its patients as evidence of the Improvements It has made In health care delivery. IntrepId Intrepid indicates Its low acute care hospitalization rates and dinlcal programs are some examples of how It Intends to Improve the delivery of care. 1!!K UHC identified several Initiatives through which It plans to gamer Improvements to health care delivery. The system-wlde plan for Improving finandal access, adaptation of programs for the monitoring and benchmarking of quality standards, utilization of a linked network of computers and Increasing public access to health care cost and quality Infonnatlon are all expected to improve UHC's . delivery of health care. All applicants mInimally meet the aiteria of this rule. Rule 111-2-2-,09(~J{n': the proposed new Institutional health service fosters the special needs and drwmsl1!1nces of health maIntenance organizations. 7he afterIa of this rule are not applicable to the projects proposed by Amedi5ys, Intrepid and UHC Amedisys and Intrepid have demonstrated their abUity to meet the goals of the State Health Plan, at a minimum, as evidenced by the fact that they have met all the aiteria of the relevant rules contained In the General RevIew Considerations and Home Health ServICES Addendum of the State Health Plan. Consequently, further review under Rule 111-2-2-.08(1 J(h) Is required to detennlne the best proposal to meet the numerical unmet need In SSDR 8. . Rule 111-2-2-~08{1J{h': In evaluating bat1:hed applications, If any or all of the batched applications equally meet the statutory considerations, pr/orfty consideration will be given to a comparison of the applications with regard to: 1. -me past and present records of the facility, and other existing facilities In GeorgIa, If any, owned by the same parent organization, regarding the provision of servIre to aU segments of the population, particularly induding Medicare, Medicaid, minority patients and those with Hmlted or no ability to pay; In its evaluation of Rule 111-2-2-,32(3)(1) and Rule 111-2-2-.09(1)(9). the Department disa.tssec:l the level of Medicare and Medicaid and indigent and charity care provision of the appRcants. Although, the provision of Indigent and charity care by home health agencies has been less than the mandatory three percent (3%) commitment, the Department continues to monitor the perfonnance of agendes, which desire expansion or to establish a new agency. The Department preference is that home health agencies provide the committed level of Indigent and charity care services, which is the crux of the commitment, versus paying timely monetary shortfalls. The Department finds that Amedisys has demonstrated its ability to adequately serve the indigent and charity population as evidenced by Its ability to meet its committed level cif care through the direct provision of services. Similarly, Intrepid has demonstrated its ability to provide a higher level of services to the Medicaid population in Its current service area. Both applicants have documented their commitment to Improving access to these special groups and have submitted plans for better meeting the needs of the Indigent population. SSDR 8 Home Health Batchlng Evaluation of Projects March 13. 1007 Page 17 .. . .-" , . Amedisys and Intrepid meet the aiteria of this rule, 2.. Specific services to be offered; Both applicants are proposing to offer a variety of specialized home care services. Amedlsys and Intrepid meet the criterion of this rule 3, Appropriateness of the site, le, the accessIbility to the population to be served, availabIlity of utilities, transpottation systems, adequacy of size, cost of acquIsition, and cost to develop; As discussed In the evaluation of Rule 111-2-2-.09fl)(f), the applicants either have existing administrative offices or have proposed leasing office space upon approvaL As sum there are no associated 8CXIuIsltlon or development costs. Furthermo~ home health services are delivered to IndMduals In their place of resfdence and are thus highly accessible to the population to be served. Amedisys and Intrepid meet the aiterion of this rule 4. Demonstrated readIness to implement the project, induding commitment of finandng. To evaluate the applicants' readiness to Implement the project:, the Department reviewed the availability of funds and the applicant's preparation to develop or expand its service in $OR 8. As discussed In Rule 111-2-2-,09(JJ(d), the applicants have adequately documented the availability of funds needed to implement the projects as proposed. The strength of an applicants'mmmunity linkage plan Is Indicative of their readiness to implement the proposed project. In the Department's review of Rule 111-2-2-.32(3)(dt the applicants provided cxmmunlty Unkage plans to demonstrate the steps they have taken to develop relationships In their new service areas and a strategy for fostering these relationships In the future. Due tn the mmpetitive nature of this process, the strengths of the mmmunlty linkage plans and efforts exhausted are a significant factor In the review process. As an existing provider of services in the region, Ame<flSYS has laid a foundation on which tn develop future mmmunlty Unkage relationships within the expanded service area as is evidenced by its growing utilization in its limited service area. The Department expects AmeOasys will continue tn have a positive impact on the health care delivery system in SSDR 8. In comparison, the community linkage plan submitted by Intrepid does not adeql!8te1y demonstrate its ability to establish relationships in the region. Intrepid provided a good faith plan that Is speculative in nature, whereas the utilization of services provided by Amedisys has demonstrated Its ability to establish and maintain mmmunity linkage plans. Amecf'fSyS best meets thIs aiterlon of the rule. IntrepId does not meet this aiterion. 5. Patterns of past performance, If any, of the applicants In implementing previously approved projects in a timely fashion; Amedisys provided documentation to reflect the timely implementation of previously approved projects. There Is no indication that Intrepid's past performance In Implementing previously approved projects has been anything but acmrding to the timeframes as required by the Department Amedisys and Intrepid meet the aiteria of thIs rule. SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 18 " ."., .c1 " ...- , . 6. Past reaxd, if any, of the applicant facility, and other existing facilities owned by the same parent organlz11tion, If any, In meeting Rcensure requirements and factors relevant to providing am;sslble, quality health care; In Its evaluation, the Department reviews the aJrrent record of the applicant or affiliate In meeting licensure requirements. The Department has verified that neither applicant has current, uncorrected licensure defidencles. Amedisys and Intrepid meet the aiterion of this rule. 7. Evidence of attention to factors of 0JSt containment, which do not diminish the quality of care or safety of the patient, but which demonstrate sincere efforts to avoid significant costs unrelated to patient care; and Home health care by Its very nature Is a more cost effective alternative In healthcare as Is evidenced by the proposed costs and charges. The proposed counties will allow for the sharing of admInistrative overhead costs affiliated organizations aJrrently operating InSSOR 8 or In the state, which will serve to lower overall overhead costs. This sharing of resources Is expected to enhance administrative productivity while reducing its operating costs for both applicants. Amedisys and Intrepid meet the aiterion of this rule. 8. Past compliance, if any, with survey and post-approval reporting requirements and Indigent and charity care commitments. Amedisys and Intrepid have been compliant with past survey and post approval reporting requirements. In Its evaluation of Rule 111-2-2-.1.32)(3)(0 and Rule 111-2-.09(1)(C/), the Department determined that AmeOI5Y5, as the only appUcant In the batx:h to meet Its Indigent and charity commitment through the direct provision of care, has demonstrated Its ability to provfcle a larger portion of care to this special population. In comparison, Intrepid provided only a limited amount of Indigent and charity care and thus Is not as finandally a<x:2SsIble as Amedisys. Amed"JSyS best meets the a/teria of this rule. Intrepid does not meet the aiteria of this rule. Rule 111-2-2-.09(1.}{a):The proposed new Institutional health services are reasonably consistent with . the relevant general goals and objectives of the State Health Plan. The Home Health Services Component Plan states the following goal: "to ensure that Georgia dtizens have access to cost-effective, efficient, and quality home health services." Due to the competitive nature of the home health batching review process, the Department carefully evaluates the proposals to determine the best alternative to meet the needs of the service area. Factors such as historical finandal accessibility with regard to Indigent and charity care, Medicare and Medicaid provision, community linkages, and quality of service are heavily weighed to detel1lllne the project with the optimal benefit to the selVlce area. Amedisys has demonstrated its ability to meet this goal as evidenced by the fact that It ~as met all the criteria of the relevant rules contained In the General Review Considerations and Home Health Services Addendum of the State Health Plan. Consequently, the proposed services of this agency have been detE}rmlned to be consistent with the Plan's goals and objectives. SSDR 8 Home Health Batchlng Evaluation of Projects March 13, 2007 Page 19 t , . The home health servires proposed by Intrepid and UHC have been detennined to be inconsistent with the goats and objectives of the State Health Plan, given that both applicants failed the following rules : · UHC :Rule 111-2-2-.32(3)(f) iRule 111-2-2-.09flJ(eJ-. and Rule 111-2-2-.09fl){hJ:and · IntrepId: Rule 111-2-2-.08(J)(h)4and Rule 111-2-2-.08(1J(hJ8 As an experienced Amedisys Home Health of Macon Is experienced In working with- community referral sources and Its existing presence and historical performance in SSDR 8 will serve to fadlitate its expansion in the service area. Amedisys provided an extensive community linkage plan and documented its efforts In developing new relationships in the expansion areas. The inaeasing patient base of Amedisys in its current SSDR 8 service area Is a testament to the strength of the community relationships the ~pplicant has been able to develop. Additionally, Amedisys was the highest provider of Indigent and charity care In SSDR 8, one of only a few to actually meet Its commitment through the direct: provisIon of care. As discussed extensively in the evaluation of Rule 111-2-2-.32(3Jm and Rule 111-2-2-.09flJ{g), home. health agendes have historically had low indigent and charity care perfonnance. Amedisys' performance Is Indicative of the effectiveness of its efforts to ensure increased financial aa::esslblrtty of Its home health services. Rnally, Amedisys has proposed to meet all the need In SSDR 8, except for Schley and Taylor Counties, where It currently provides service. Despite befng an existing provider In these counties, the Department's need calculation reflected a need of 35 and 4S patients respectively. Amedisys is only one of eight providers In Schley County. The numerical need as calculated by the Department is based on a projection three years inm the future. Therefore the numerical need by Itself Is not an accurate measure of the current need In the county or the effectiveness of existing agencies to meet that need. The historical utilization of Amedisys Indicates that the applicant is In. fact meeting the home health service needs for an lnaeasing number of presenters for care. For these reasons and those discussed In this evaluation, Amedisys has been determined to be the superior applicant for the expansion of home health services In SSDR 8. Amedisys meets the aiteria of this rule. Intrepid and UHC do not meet the criteria of this role. SSDR 8 Home Health Batching Evaluation of Prolects March '13, 2007 Page 20 . , . . . CONCLUSION Amedisys Horne Health of Macon, Intrepid USA Healthcare Servlces and United Home Care have each requested a Certificate of Need to expand or establish newhorne health services In State Service Delivery Region 8. Based on the evaluation findings of the Certificate of Need Rules relevant to the projects proposed, It is the decision of the Georgia Department of Community Health, Division of Health Planning to ISSUE a Certificate of Need to Amedisys Home Health of Macon to expand Its home health services to Include Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Stewart, Sumter and Talbot. These Counties show a need for 621 patients. Amedisys currently serves Taylor, Schley and Muscogee counties In SSDR 8. The total estimated cost for the proposed project Is $125,000. It is the decision of the Georgia Deparbnent of Community Health, DMslon of Health Planning to DENY a Certificate of Need to Intrepid USH Healthcare ServIces, Inc to establish a new home health agenc.y to serve the following counties: Olattahoochee, Oay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These counties show a need for 702 patients. The pro.1ecthas a total estimated cost of $70,000. It Is the decision of Georgia Department of Community Health, DMslon of Health Planning to DENY a Certificate of Need to United Home Care of South west Georgia, Ine ("UHC") to establish a new home health agenc.y to service the following counties: Chattahoochee, Oay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot and Taylor. These oounties show a need for 702 patients. The project has a total estimated cost of $228,363. Additionally, the certificate is valid for a period of twelve (12) months, unless extended for good cause. It Is Important that the administration of your project be consistent with the Certificate of Need rules. Accordingly, a copy of "Post Approval Requirements," which outlines the duraUofl, progression, and extension provisions (If needed) that apply to this approval Is available at the Department's webslte: www.georgla.aov. Please be advised that a decision by this Department Is subject: to appeal within thirty (30) days from the date of this letter. Should a bona fide request for an appeal be received, you Will be promptly notiflecl and the Certificate of Need will be suspended until the appeal Is resolved. You are strongly advised not: to make a substantial obligation of funds until the time period for requesting an appeal has expired. The approval of a project by the Deparbnent of Community Health, Division of Health Planning does not assure that any amount or rate of reimbursement will be paid by the Division of Medical Assistance, the Medicare intermediary, or any other payment source. SSDR 8 Home Health Batching Evaluation of Projects March 13, 2007 Page 21 " UiISJP.PRUITT CORPORATION Cummitted tu Caril1J ~ ~~~n~~ OCT 1 6 Z006 lW DIVISION OF HEALTH PLANNING October 16, 2006 Certificate of Need Batching Notices ofIntent Department of Community Health Division of Health Plamring 2 Peachtree Street, NW 5th Floor Atlanta, Georgia 30303-3142 RE: United Home Care of SouthWest Georgia, Inc. Letter of Intent to file a Certificate of Need in SSDR 8 To whom it may concern: On behalf of United Home Care of South West Georgia, Inc., please accept this Letter of Intent to file a Certificate of Need application in SSDR 8. United Home Care of South West Georgia, Inc. will file as a new agency to serve the following counties: Chattahoochee Clay Harris Macon Marion Quitman Randolph Schley Stewart Sumter Talbot Taylor These counties will be the service area for the proposed new home health agency. z/ a 1;J;\~ Neil L. Pruitt, Jr. Chairman & CEO EXHiBlt'f B " 3945 Lawrenceville Hwy. . Lilburtl, Georgia 30047 . (770) 806-6802 · Fax: (770) 925-0922 , . I SSDR8 J MASTER FILE 'I; =.:~=.~ Georgia Certificate of Need Application ... FOR CERTIFICATE OF NEED OFFICE USE ONLY . a ,. 0 '. .. . . PROJECT NUMBER OA-TE-STAMP--.---- ~ IE (c; IE ~ \W ~:l1 GA NOV 1 3 2005 I~ 200G-132.:w - DIVISION OF HEALTH PLANNING COUNTY: Signed Original and 3 Copies 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 Departmenfs website. www.dch.state.aa.us. 1. Applicants must submit a signed original and one copy of the signed application and the appropriate filing fee. 2. The filing fee shall be made payable to the "State of Georgia" and shalt be remitted by Certified Check or Monev 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 APPUCAnON. i . . . - ..~.. . 1. Have you submitted an original signed in blue ink and provided 3 copies of this 181 Yes signed application? DNo 2. Enter Total Cost Applicable to Filing Fee (From Line 16. QuesUon 22. Page 13) $209,113.00 3. Calculate the Filing Fee and Total Amount Due (Check one of the following and enter the amount in the column to the right) 18I Line 2 is between 0 to $1 million'" Enter $1,000.00 $1,000.00 DUne 2 is between $1 million and $50 million .. Enter Une 2 x .001 o line 2 is greater than $50 million .. Enter $50.000.00 .. 4. Have you submitted a Certified Check or Money Order made payable to "State l8IYes of Georgia" for the amount listed in Line 3 above? DNo Submit to: Certificate of Need Program Department of Community Health 2 Peachtree Street, NW - 40th Floor Atlanta, GA 30303 li!\ 2 2 Z007 , . , . . ~ United Home Care of South West Georgia, ~nc. . . ~ " r ~ Certificate of Need Application l For the EstabUshment 'of a New Home Health .?\.gency ~ .. In SSDR 8 - ~ , ~ ~ (Chattahoochee, Clay, Harris, Macon, Ma~on, Quitman, Randolph, Schley, Stewart, Sumter,tTalbot, and Taylor Counties) ~ . .i r ~ 1 ~ I ~ ~ ~ 1 I' ~ ~ . ~ November 2006 , ' '.*-.! -. ;~ .:'~;:~,:- . ~/. :';:=-::;'t.~) if/ ~:5;:QRG~lz~tlafj~'~bC'iiiji:1~~~';~:::~:5~~,~~',~-;.:;'t ~~~'t.<'~:/fi,~;:;'; . . ;~~t~"f-~ '.:.~i{~.?~~~:~~!~~: "SO"'PiOp~;>\~'~'.r~ ~S;'~',:~>!~2~{J:~ :'~;.~':-; ~~:~~J;~:,I,~ijl~;l.~;. :98fteral:~"~~'P..1~ i~;~;.~~\~i.~ f_~~::f.'~:~~~~Y;:: :st;.~f~{t:;~i:t1f: ;':I:-I.,.n.tJt~~IIty_.' >~; -,>.) 2:{!;W ;;;;,:y~;lf:fl&;:i:q~ 'B~sI~esa';.',;;; r{\<':i..\~... ~~Jl~1},;~ ;~~~;l;:.~}~:~~t~Jt~~ Umlt8d'Uablpty:'+.. ..... ,I' 'f0~1Y~;~i~~ o County and Municipal Government Business Authorization Documents (e.g. Licenses, Permits. Be.) o Bylaws o Organizational Chart(s) o Name, Partnership Interest, and Percentage Ownership ot Each Partner o Partnership Agreement o Certificate of Existence o Bylaws o Organizational Chart(s) o Name, Partnership Interest, and Percentage Ownership of Each Partner o Partnership Agreement , o Certificate of Existence o Certificate of Registration o Articles of Organization o Bylaws o Organizational Chart(s) ~ Name of Each Officer and Director ~ Articles of Incorporation IZI Certificate of Existence 181 Bylaws ~ Organizational Chart(s) o Application/Authorization to do Business in Georgia (for Non-Resident Corporations) o Name of Each Officer and Director o Articles of Incorporation o Operating Agreement o Certificate of Existence o Bylaws o Organizational Chart(s) o 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 Umited 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. The applicant is United Home Care of South West Georgia. Inc. (UHC--Sou1h West Georgia) and is wholly owned by United Health Service$ of Georgia, Inc. (UHS of Georgia). UHS of Georgia. Inc. is wholJy owned by United Health Services, Inc. (UHS). UHS of Georgia. Inc. is a vertically integrated provider of post-acute health care services which, through its subsidiaries. owns and operates a variety of health care services across Georgia, North Carolina and South Carolina including Hospice, Nursing Home, Assisted Uving, Rehabilitation, Pharmacy, Medical Supplies, Home and Community Based services and Home Health services. UHS and UHS of Georgia, tnc. are widely known in the health care industry as UHS-Pruitt Corporation or UHS-Pruitl. Please see Appendix C for a copy of organizational charts of United Health Services, Inc. and its subsidiaries. UHS of Georgia operates four Home Health agencies in Georgia. Together these agencies are known in the industry as United Home Care (UHC). CoUeclively UHC serves a 36-c0unty area that includes all of metropolitan Atlanta and most of North Georgia The new agency proposed in the application will operate as an affiliate company of UHC and will be known as United Home Care of South West Georgia. State of GeoJVia: Certificate of Need Application Form CON 100 Revised September 2006 Section 1 Page .. , ' 18. Provide a detailed description of the proposed project including a listing of the departments (e.g. ED. leU), , . services. (e.g. Home Health, Cardiac Cath). and equipment (e.g. MRI, PET, Cath) involved. Cir NOTE: If your description exceeds this blocked space, attach additional8-~ 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. In response to an identified need for home health services by the Department of Community Health, UHC of South West Georgia, Inc. (UHC-South West Georgia) proposes to develop a new home health agency in State Service Delivery Region (SSDR) 8 to serve Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot. and Taylor Counties. The main office will be located in Sumter County. The new agency proposed in this application will operate as part of a larger integrated health delivery system known in the industry as UH5-Pruitt. UHS-Pruitt operates, through its subsidiaries known as United Home Care, or UHC, 4 home health agencies in Georgia These agencies provide home health services to 36 Georgia counties. The proposed new agency, (UHC-South West Georgia), will operate as a division of UHC. The extensive resources of UH5- Pruitt and UHC available to implement the proposed project are key to the prompt development of cost effective and high quality home health services for the area. These resources are discussed in greater detail throughout this document. This document will demonstrate that UHC-South West Georgia is the best applicant to meet the unmet need in SSDR 8. UHC-South West Georgia, as part of UHS-Pruitt, proposes to change the way in which home health care is delivered and integrated into Georgia's long-term care system. A focus on transoarencv permits the consumer to make informed choices based upon quality and cost, and an emphasis on access and technoloav in the provision of health care makes this project and this applicant unique. . UHS-Pruitt and Its affiliates have been innovative leaders in health care delivery in(Georgia. For example. UHS-Pruitt was instrumental in the success of Georgia's SOURCE program during its demonstration phase. When Georgia included the program in its State Plan, UH5-Pruitt expanded this Innovative program to 114 counties across the state. Further examples of innovation and initiative by UHS-Pruitt include: · The Blue Ridge Integrated Continuum of Care Model, which integrates Home Health, Day Care, SOURCE, Personal Support Services, Respite Services, Skilled Nursing Facility care, and Hospice in rural North Georgia; · The UHS-Prultt proposal to partner with DCH and CMS on the development of a rural for- profit PACE program; · The United Pharmacy Services program to participate in the management of medication regimes for United Hospice and UniHealth SOURCE patients; and · UHS-Pruitt's participation in the My Innerview program. Continued on Page 9.1. State of Georgia: Certificate of Need Application Form CON 100 Revised September 2006 Section 2 Page 9 , . . . Page 9 continued Consistent with this corporate philosophy of innovation, and inspired by the Governor's recent executive order creating the Health Information Technology and Transparency Advisory Board, UHS-Pruitt is committed to 11 strategies which it will implement as part of the proposed new home health agency, these plans are summarized below. These plans include: · Commitment to Transoarency in Qualitv and Pricing - Consistent with the Governor's initiatives, UHS-Pruitt will ensure pricing transparency by providing pricino information and Quality benchmarkino data through public sources such as the internet, local newspapers, public agencies, and to referral sources such as discharge planners. · Commitment to Increase Access for those in Rural Counties - UHS-Pruitt is committed to increasinQ access to quality home health services particularly in rural communities. UHS-Pruitt and UHC have extensive experience in serving Georgia's rural counties. UHC will use the strategies it has learned in other areas of the state to ensure that those residing in the rural areas of the proposed service region are aware of and can easily access home health services · Commitment to Increase Financial Accessibility for the Uninsured - UHC is committed to providing financially accessible home and community-based services to the communities it serves. UHC-South West Georgia commits, as part of this application, to provide at least 3 percent of adjusted gross revenue to indigent/charity care patients. UHC - South West Georgia developed a locally fociJsed operating plan to ensure that this care is provided to patients in the proposed service area regardless of their ability to pay · Commitment to Integrate with Existing Community Resources - UHC- South West Georgia's patients will have access to a coordinated. integrated delivery system implemented through a combination of UHS-Pruitt services and linkages with existing health care facilities, services, physicians, and other agencies and organizations. The UHS-Pruitt model of care develc;>ped in North Georgia will be integral to the service delivery policies and procedures of the proposed agency. · Commitment to Service Delivery in the Safest and Most Aopropriate Settina - UHS-Pruitt's participation in programs such as SOURCE, Georgia's Community Care Services Program, and DCH's Nursing Home Transitions demonstration project have provided insight into the most effective approaches to ensure that patients have alternatives. The strategies UHS- Pruitt has learned both prevent long-term institutionalizat~on and provide a Slate of Georgia: Certificate of Need Application UHC-South West Georgia Section 3 Page 9.1 , . , . means to transition nursing home patients back to a community based care setting. · Commitment to Utilize Information Technoloav - UHS-Pruitt is a pioneer in utilizing technology to help serve its patients in a higher quality, safer, and more cost efficient manner. UHS-Pruitt and UHC will continue their efforts to develop and deploy information technology in the areas of patient care, quality assurance, stakeholder satisfaction, and integration. · Commitment to Quality Cost Effective Care - UHC's existing agencies are fully accredited by JCAHO. UHC-South West Georgia is committed to delivering quality home health care to the proposed service area and will seek JCAHO accreditation as soon as possible after initiation of services. UHC- South West Georgia will utilize My Innerview @ and other surveys and audits done by UHC. and United Clinical Services. These measures will be made publicly available through the agency's transparency initiatives. · Commitment to Innovation Throuah Research Partnerships - UHC has designed several study projects to identify home health clinical "best practice" policies in selected areas. · Commitment to Ensure Safe and Cost Effective Use of Pharmaceuticals - UHS-Pruitt has an extensive pharmacological and pharmacy management resources through United Pharmacy Services. United Pharmacy conducts medication reviews of patients at all levels of care within the UHS-Pruitt continuum of services. Medication reviews have resulted in significant improvements in patient outcomes, as well as real cost savinQs to public and private payers by eliminating potentially dangerous drug combinations, duplications of medications, and drugs that counter-effect another drug in combination. UHC and United Pharmacy Services are currently engaged in discussions regarding Pharmacy intervention and management for Home Health patients · Commitment to Clinical Trainlna and Reducina Health Manpower Shortages - UHC - South West Georgia will support local training of clinical and health care management personnel. UHC-South West Georgia will offer a $15,000 scholarship through a local academic/technical institution for students interested in clinical health fields. UHC-South West Georgia will also sponsor and implement a focal preceptor program that may be tailored to the needs of the local market. These additional resources will contribute to the State's ongoing efforts to address the Manpower Shortages. · Commitment to Human Resources - UHS-Pruitt is committed to recruiting and retaining highly qualified employees. Retention efforts include educational opportunities, including internal training and scholarships, employee satisfaction analysis, the availability of corporate Chaplains, a not State of Georgia: Certificate of Need Application UHC-South West Georgia Section 3 Page 9.2 , ' B. Objectives 1. Improve access to cost effective, quality home health services by authorizing these services based on a demand-based numerical need methodology. UHC's proposal to develop a new home health agency to serve residents of Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, and Taylor Counties responds to the need for home health services in these counties identified by the Department of Community. Health, Division of Health Planning and published in the Batching Review Cycle Notification for Home Health Services in September 2006. 2. Ensure quality and patient safety through compliance with appropriate standards and guidelines. UHC-South West Georgia will operate as a division of UHC, an existing Georgia provider of home health services. UHC and all of its affiliates are committed to the delivery of safe high quality in home care for the citizens of the State. UHC and all of its affiliated Home Heath Agencies are fully accredited by the Joint Commission on the Accreditation of Health Care Organizations, (JCAHO). If it is awarded the Certificate of Need for SSDR 8, the applicant will also become accredited. Appendix E provides documentation of UHC's accreditation status through JCAHO. In addition to its JCAHO accreditation, UHC has: a) Selected Press Ganey, a leading satisfaction measurement and improvement firm, to assist UHC in assessing the quality of care that is provided to their patients. A patient satisfaction survey developed by Press Ganey is provided to each patient upon discharge. Press Ganey analyzes and interprets the results of the patient surveys and then produces reports to aid UHC in identifying areas that need improvement. UHC's home health agencies have consistently ranked very high amongst its peers in all patient care areas surveyed. An excerpt of the results from the most recent satisfaction survey is provided as Appendix E. b) Been actively engaged with CMS's Quality Improvement Organization, (QIO), fot Georgia. c) Become members of the CMS task force studying reducing the acute care hospitalization rate of Home Health patients, improving the use of oral medications, use of tele-health programs, and disease state management. UHC and its affiliates are also experimenting with a national health care benchmarking firm which provides data on employee and family satisfaction as well as specific indicators of patient care (My Innerview). Slate of Georgia: Certificate of Need Application United Home Care of South West Georgia Section 3 Page 10.8 , ' III. UHC-South West Georgia is The Best Applicant to Meet the Need A. Consistency with the Governors Best Practices and Federal Initiatives UHC. as part of a larger organization UHS - Pruitt, has an unparalleled ability to develop home health services in SSDR 8. UHS-Pruitt and UHC are committed to developing a health care delivery system that is consistent with goals and initiatives identified by the Governor and the State Health Plan. UHC-South West Georgia has discussed its initiatives to achieve these goals in great detail throughout this application. It has also identified the actions it will take to meet a number of other CMS initiatives to enhance consumer awareness, ensure patients are able to make informed decisions with respect long-term care. and to assist patients who can be safely cared for, to return home. These initiatives will also be discussed throughout this document. However. it is important to have a full understanding of the ability of the organization to execute these actions. UHS-Pruitt and UHC are described in detail below. B. Overview of UHS- Pruitt and UHC - South West Georgia's Strengths UHC-South West Georgia, through its affiliation with UHS-Pruitt and UHC, is ideally positioned to meet the identified need for home health services in the proposed service area. UHC is an experienced provider of home health services and has the infrastructure and capacity to implement the proposed project quickly and efficiently. Furthermore. UHS-Pruitt already provides hospice, pharmacy. rehab and medical supply services to the residents in SSOR 8 and adjacent regions. Affiliations with these existing providers will enhance the continuum of services available to the residents of the proposed service area. UHC's affiliation with UHS-Pruitt provides it with the capital, human. and clinical resources to promptly develop new home health services in the region. UHC-South West Georgia. as part of UHS-Pruitt. is the best applicant to meet the need in SSDR 8 based on the following strengths: . Commitment to Community linkaoes - UHC-South West Georgia's patients will have access to a coordinated. integrated delivery system implemented through a combination of UHS-Pruitt services and linkages with existing health care facilities, services. physicians, and other agencies and organizations. As part of these linkages, UHC- South West Georgia will implement a local advisory board in the service area comprised of stakeholders from the community. Please see Appendix K for a detailed community linkage plan for the proposed new agency. Slate of Georgia: Certificate of Need Application UHC-South West Georgia Section 3 Page 11.11 , , . Commitment to Rural Health - UHC is committed to increasing access to quality home health services particularly in rural-communities. The proposed development of a new home health agency by UHC will increase access to the rural areas of the twelve-county area. Please see the discussion later in this response regarding the provision of rural health care services. . Commitment to Financial Accessibility - UHC is committed to providing financially accessible home and community-based services to the communities it serves. UHC-South West Georgia commits as part of this application to provide at least 3 percent of Adjusted Gross Revenue to indigent/charity care patients. UHC will develop a localized plan to ensure that this care is provided to patients in the proposed service area. . Commitment to Minimize Institutional Care - UHS-Pruitt's participation in community outreach programs such as SOURCE, Georgia Medicaid's Community Care Services Program, and its expansion of its SOURCE services into all of Georgia's counties demonstrates UHC's commitment to ensure that individuals receive services at the most appropriate and efficient level of care. 'UHC's affiliation with such programs as SOURCE and CCSP will increase patients' options to long term institutionalization. . Commitment to Information TechnoloQ~ - UHS-Pruitt is a pioneer in utilizing technology to help serve its patients better and offer higher quality of care. All community based services use a single unified information system. Point of Care technology is also used by UHC. It will be implementing Electronic Medical Records to provide efficient care to its patients. UHC will initiate research into the use of tele- health to contact physicians while in a home care setting. This is particularly critical in rural areas where physician specialists may be less available. . Commitment to Transparencv in Quality and Pricina - UHS-Pruitt will ensure pricing transparency by providing pricing information through public sources such as the internet, newspaper, and directly to referral sources such as discharge planners. UHS-Pruitt will also make quality comparison and benchmarking data available in much the same way. . Commitment to Accreditation - UHC's existing agencies are fully accredited by JCAHO. UHC - South West Georgia is committed to delivering quality home health care to the proposed service area and will seek JCAHO accreditation as soon as possible after initiation of services. Slate of Georgia: CertifICate of Need Application UHC-SOuth West Georgia Section 3 Page 11.12 , ' at the appropriate level of care and low acuity patients are kept out of the nursing home setting also promotes efficiency in the health care delivery system. As an existing provider of home health services, UHC is committed to ensuring quality and patient safety through compliance with appropriate standards and guidelines. All of UHC's existing agencies are fully accredited by JCAHO. UHC will ensure that its agencies continue to meet or exceed the standards of care identified by the accreditation guidelines of JCAHO. Similarly, UHC will continue to meet or exceed all of the standards of care required by Medicaid, Medicare, and State licensure. Please see Appendix E for a copy of UHC's JCAHO accreditation. The provision of high quality care will be further ensured by internal quality assurance standards that are currently in place at UHC. A copy of UHC's performance improvement program is provided as Appendix E. B. Financial Accessibility UHC will bring greater financial accessibility to services for patients living in Chattahoochee, Clay, Harris, Macon, Marion, Quitman, Randolph, Schley, Stewart, Sumter, Talbot, and Taylor Counties, including the Medicaid population (through SOURCE) as well as indigent and charity care patients. There were also 22,583 uninsured residents in these counties in 2000. UHC will be able to provide care to this segment of the population. UHC has always fulfilled its charity care commitment by providing a combination of services and payment of shortfalls. Although the charity care commitment is challenging to meet as experienced by all home health care providers, UHC has developed a comprehensive and aggressive plan to not only identify the uninsured and underinsured population but also to identify a way to serve them. This will be particularly critical given that the number of uninsured residents of SSDR 8. As a part of this application, UHC-South West Georgia is making a commitment to provide at least 3 oercent of adjusted gross revenue as uncompensated indigent/charity care. Furthermore, UHC will develop a specific operational indigent care plan to implement in SSDR 8 to ensure all referring facilities and agencies are aware of UHC's intent to provide uncompensated indigent/charity care. C. RebalancIng Health Care Dollars A publication by Center for Health Transformation (included in Appendix E) discusses best practices in Medicaid. In Georgia, those practices include Disease Management Programs that are currently being provided in 112 counties State of Georgia: Certificate of Need Application UHC.South West Georgia Section 3 Page 11.28 , . Appendix E JCAHO Letter .. . . . . . o. .. , ' Joint Commission an Ac~tedltltID1l of ~81Murs Orpnlz,tlDIII '$eIting IhI: SfantfanllDr Duality iff IfealItlCare August 16.2006 Neil L. Pruitt. Jr.. MBA Chief Executive Officer United Home Care. Inc. 394) LawrenceviUe Highway Lilbum. GA 30047 Joint Commission 10 #: 373674 Accreditation Activity: Evidence of Standards Compliance Accreditation Activity Completed: 8/1612006 Dear Mr. Pruitt: The Joint Commission would like to thank your organization for participating in the Joint Commission's accreditation process. This process is designed to help your organi