Effective 2-22-95

59C-1.039 Comprehensive Medical Rehabilitation Inpatient Services

(1) Agency Intent. This rule implements the provisions of subsections 408.034(3), 408.034(5), paragraphs 408.036(1)(a), (b), (d), (j) and (k), and subsection 395.003(4), Florida Statutes. It is the intent of the agency to ensure the availability of comprehensive medical rehabilitation inpatient services for persons in need of these services, including Medicaid and charity care patients. This rule regulates the establishment of new comprehensive medical rehabilitation inpatient services, the construction or addition of new comprehensive medical rehabilitation inpatient beds, and the conversion of licensed hospital acute care beds to comprehensive medical rehabilitation inpatient beds.

(2) Definitions.

(a) "Approved Comprehensive Medical Rehabilitation Inpatient Bed." A proposed comprehensive medical rehabilitation inpatient bed for which a certificate of need, a letter of intent to grant a certificate of need, a signed stipulated agreement, or a final order granting a certificate of need was issued, consistent with the provisions of 59C-1.008(2)(b), Florida Administrative Code, as of the most recent published deadline for agency initial decisions prior to publication of the fixed need pool, as specified in paragraph 59C-1.008(1)(g), Florida Administrative Code.

(b) "Charity Care." As defined in subsections 409.2663(2) and 409.911(1), Florida Statutes, charity care is that portion of hospital charges for which there is no compensation for care provided to a patient whose family income for the 12 months preceding the determination is less than or equal to 150 percent of the current Federal Poverty Guidelines (FPG), as published in the Federal Register; or for which there is no compensation for care provided to a patient whose family income for the 12 months preceding the determination is greater than 150 percent of the current FPG but not more than four times the current FPG for a family of four and the amount of hospital charges due from the patient exceeds 25 percent of the 12-month family income. Charity care does not include bad debt, which is the portion of health care provider charges for which there is no compensation for care provided to a patient who fails to qualify for charity care; and does not include administrative or courtesy discounts, contractual allowances to third-party payors, or failure of the hospital to collect full charges due to partial payment by government programs.

(c) "Comprehensive Medical Rehabilitation Inpatient Services." An organized program of integrated intensive care services provided by a coordinated multidisciplinary team to patients with severe physical disabilities, such as stroke; spinal cord injury; congenital deformity; amputation; major multiple trauma; fracture of femur (hip fracture); brain injury; polyarthritis, including rheumatoid arthritis; neurological disorders, including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson's disease; and burns.

(d) "Department." The Agency for Health Care Administration.

(e) "District." A district of the agency defined in subsection 408.032(5), Florida Statutes.

(f) "Fixed Bed Need Pool." The numerical comprehensive medical rehabilitation inpatient bed need for the applicable planning horizon, as established by the agency in accordance with this rule and subsection 59C-1.008(2), Florida Administrative Code.

(g) "General Hospital." A hospital which provides services to the general population and does not restrict its services to any specified category of disorders or to any specified age or gender group of the population, as defined in subsection 395.002(4), Florida Statutes.

(h) "Local Health Council." The council referenced in section 408.033, Florida Statutes.

(i) "Planning Horizon." The projected date by which a proposed comprehensive medical rehabilitation inpatient service would be initiated. For purposes of this rule, the planning horizon for applications submitted between January 1 and June 30 is July of the year 5 years subsequent to the year the application is submitted; the planning horizon for applications submitted between July 1 and December 31 is January of the year 5 years subsequent to the year which follows the year the application is submitted. For example, an application submitted in March 1991 would have a planning horizon of July 1996; an application submitted in September 1991 would have a planning horizon of January 1997.

(j) "Separately Organized Unit." A specific section, ward, wing, or floor with a separate nursing station designated exclusively for the care of comprehensive medical rehabilitation patients.

(k) "Specialty Bed." A category of hospital inpatient beds for which the agency has promulated a separate rule specifying need determination criteria, including burn unit beds, hospital inpatient general psychiatric beds, hospital inpatient substance abuse beds, Level II and Level III neonatal intensive care unit beds; and the comprehensive medical rehabilitation inpatient beds regulated under this rule.

(l) "Specialty Hospital." A hospital which restricts its services to a specified category of disorders or to a specified age or gender group of the population, as defined in subsection 395.002(14), Florida Statutes.

(3) General Provisions.

(a) Service Location. The comprehensive medical rehabilitation inpatient services regulated under this rule may be provided in a hospital licensed as a general hospital or licensed as a specialty hospital.

(b) Separately Organized Units. Comprehensive medical rehabilitation inpatient services shall be provided in one or more separately organized units within a general hospital or specialty hospital.

(c) Minimum Number of Beds. A general hospital providing comprehensive medical rehabilitation inpatient services should normally have a minimum of 20 comprehensive medical rehabilitation inpatient beds. A specialty hospital providing comprehensive medical rehabilitation inpatient services shall have a minimum of 60 comprehensive medical rehabilitation inpatient beds. Hospitals with licensed or approved comprehensive medical rehabilitation inpatient beds as of the effective date of this rule are exempt from meeting the requirements for a minimum number of beds.

(d) Conformance with the Criteria for Approval. A certificate of need for the establishment of new comprehensive medical rehabilitation inpatient services, the construction or addition of new comprehensive medical rehabilitation inpatient beds, or the conversion of licensed hospital acute care beds to comprehensive medical rehabilitation inpatient beds shall not normally be approved unless the applicant meets the applicable review criteria in section 408.035, F.S., and the standards and need determination criteria set forth in this rule.

(e) Medicare and Medicaid Participation. An applicant proposing to increase the number of licensed comprehensive medical rehabilitation inpatient beds at its facility shall participate in the Medicare and Medicaid programs. Applicants proposing to establish a new comprehensive medical rehabilitation inpatient service shall state in their application that they will participate in the Medicare and Medicaid programs.

(f) Comparative Review. A certificate of need application submitted for review under this rule will be subject to a comparative review with all other certificate of need applications subject to review under this rule that propose to serve the same district and which were submitted during the same review cycle.

(g) Excluded Hospitals. Hospitals operated by the State of Florida or the federal government are not regulated under this rule.

(4) Required Staffing and Services.

(a) Director of Rehabilitation. Comprehensive medical rehabilitation inpatient services must be provided under a medical director of rehabilitation who is a Board certified or Board eligible physiatrist and has had at least 2 years of experience in the medical management of inpatients requiring rehabilitation services.

(b) Other Required Services. In addition to the physician services in paragraph (4)(a), comprehensive medical rehabilitation inpatient services shall include at least the following services provided by qualified personnel:

1. Rehabilitation nursing

2. Physical therapy

3. Occupational therapy

4. Speech therapy

5. Social services

6. Psychological services

7. Orthotic and prosthetic services.

(5) Criteria for Determination of Need.

(a) Bed Need. A favorable need determination for proposed new or expanded comprehensive medical rehabilitation inpatient services shall not normally be made unless a bed need exists according to the numeric need methodology in paragraph (5)(c) of this rule.

(b) Fixed Bed Need Pool. The future need for comprehensive medical rehabilitation inpatient services shall be determined twice a year and published by the agency as a fixed bed need pool for the applicable planning horizon.

(c) Need Formula for Comprehensive Medical Rehabilitation Inpatient Beds. The net bed need for comprehensive medical rehabilitation inpatient beds in each district shall be calculated in accordance with the following formula:

NN = ((PD/P) X PP / (365 X .85)) - LB - AB

where:

1. NN equals the net need for comprehensive medical rehabilitation inpatient beds in a district.

2. PD equals the number of inpatient days in comprehensive medical rehabilitation inpatient beds in a district for the 12-month period ending 6 months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

3. P equals the estimated population in the district. For applications submitted between January 1 and June 30, P is the population estimate for January of the preceding year; for applications submitted between July 1 and December 31, P is the population estimate for July of the preceding year. The population estimate shall be the most recent estimate published by the Office of the Governor and available to the agency at least 4 weeks prior to publication of the fixed bed need pool.

4. PP equals the estimated population in the district for the applicable planning horizon. The population estimate shall be the most recent estimate published by the Office of the Governor and available to the agency at least 4 weeks prior to publication of the fixed bed need pool.

5. .85 equals the desired average annual occupancy rate for comprehensive medical rehabilitation inpatient beds in the district.

6. LB equals the district's number of licensed comprehensive medical rehabilitation inpatient beds as of the most recent published deadline for agency initial decisions prior to publication of the fixed bed need pool.

7. AB equals the district's number of approved comprehensive medical rehabilitation inpatient beds, as determined consistent with the provisions of paragraph (2)(a) of this rule.

(d) Most Recent Average Annual District Occupancy Rate. Regardless of whether bed need is shown under the need formula in paragraph (5)(c), no additional comprehensive medical rehabilitation inpatient beds shall normally be approved for a district unless the average annual occupancy rate of the licensed comprehensive medical rehabilitation inpatient beds in the district was at least 80 percent for the 12 month period ending 6 months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

(e) Special Circumstances for Approval of Expanded Capacity at Hospitals with Licensed Comprehensive Medical Rehabilitation Inpatient Services.

1. Subject to the provisions of paragraph (7)(b) of this rule and subparagraph 2. of this paragraph, need for additional comprehensive medical rehabilitation inpatient beds is demonstrated at a hospital with licensed comprehensive medical rehabilitation inpatient services in the absence of need shown under the formula in paragraph (5)(c), and regardless of the most recent average annual district occupancy rate determined under paragraph (5)(d), if the occupancy rate of the hospital's licensed comprehensive medical rehabilitation inpatient beds was at least 90 percent for at least two consecutive calendar quarters during the 12-month period ending 6 months prior to the beginning date of the quarter of the publication of the fixed bed need pool; and at least one of the following conditions is also met:

a. The applicant submits evidence that it has a specialty inpatient rehabilitation service, accredited as a specialty by the Commission on Accreditation of Rehabilitation Facilities (CARF), that is not available elsewhere in the district, and the applicant's high occupancy occurred in the specialty rehabilitation service beds; or,

b. The applicant is a disproportionate share hospital as determined consistent with the provisions of section 409.911, Florida Statutes, and the applicant submits evidence that it has been providing both Medicaid and charity care days in its comprehensive medical rehabilitation inpatient beds.

2. The maximum number of additional comprehensive medical rehabilitation inpatient beds which may be approved at an applicant's facility under the provisions of subparagraph 1. shall not normally exceed the number determined in accordance with the following formula:

ADD = ((HPD/PD) X PPD / (365 X .85)) - HLB - HAB

where:

a. ADD equals the net number of additional comprehensive medical rehabilitation inpatient beds which may be approved under the provisions of subparagraph 1.

b. HPD equals the hospital's number of comprehensive medical rehabilitation inpatient days that were included within PD for the district.

c. PPD equals the total of comprehensive medical rehabilitation inpatient days projected for the district at the planning horizon, defined as (PD/P) X PP.

d. .85 equals the desired annual comprehensive medical rehabilitation inpatient bed occupancy rate for the hospital at the planning horizon.

e. HLB equals the hospital's number of licensed comprehensive medical rehabilitation inpatient beds included within LB.

f. HAB equals the hospital's number of approved comprehensive medical rehabilitation inpatient beds included within AB.

(f) Other Factors to be Considered in the Review of Certificate of Need Applications for Comprehensive Medical Rehabilitation Inpatient Services.

1. Applicants shall provide evidence in their applications that their proposal is consistent with the needs of the community and other criteria contained in:

a. Local Health Council District Health Plans, including the Certificate of Need Allocation Factors Reports; and

b. the State Health Plan.

2. Applications from general hospitals for new or expanded comprehensive medical rehabilitation inpatient beds shall not normally be approved unless the applicant converts a number of acute care beds, as defined in Rule 59C-1.038, Florida Administrative Code, excluding specialty beds, which is equal to the number of comprehensive medical rehabilitation inpatient beds, unless the applicant can reasonably project an annual occupancy rate of 75 percent for the applicable planning horizon, based on historical utilization patterns, for all acute care beds, excluding specialty beds. If conversion of the number of acute care beds which equals the number of proposed comprehensive medical rehabilitation inpatient beds would result in an annual acute care occupancy exceeding 75 percent for the applicable planning horizon, the applicant shall only be required to convert the number of beds necessary to achieve a projected annual 75 percent acute care occupancy for the applicable planning horizon, excluding specialty beds.

(g) Priority Considerations for Comprehensive Medical Rehabilitation Inpatient Services Applicants. In weighing and balancing statutory and rule review criteria, the agency will give priority consideration to:

1. An applicant that is a disproportionate share hospital as determined consistent with the provisions of section 409.911, Florida Statutes.

2. An applicant proposing to serve Medicaid-eligible persons.

3. An applicant that is a designated trauma center, as defined in section 10D-66.108, Florida Administrative Code.

(6) Access Standard. Comprehensive medical rehabilitation inpatient services should be available within a maximum ground travel time of 2 hours under average travel conditions for at least 90 percent of the district's total population.

(7) Quality of Care.

(a) Compliance with Agency Standards. Comprehensive medical rehabilitation inpatient services shall comply with the agency standards for program licensure described in section 59A-3, Florida Administrative Code. Applicants who submit an application that is consistent with the agency licensure standards are deemed to be in compliance with this provision.

(b) Accreditation. Applicants proposing a new comprehensive medical rehabilitation inpatient service shall state how they will meet the accreditation standards of the Commission on Accreditation of Rehabilitation Facilities (CARF) and shall state that they will seek accreditation by CARF. Applicants proposing to add beds to a licensed comprehensive medical rehabilitation inpatient service shall be accredited by CARF consistent with the standards applicable to comprehensive inpatient rehabilitation or specialized inpatient rehabilitation, as applicable to the facility; or, if not yet eligible for CARF accreditation, the applicants shall have received full Medicare certification as a rehabilitation hospital or rehabilitation unit, as applicable to the facility.

(8) Services Description. An applicant for comprehensive medical rehabilitation inpatient services shall provide a detailed program description in its certificate of need application including:

(a) Age groups to be served.

(b) Specialty inpatient rehabilitation services to be provided, if any (e.g. spinal cord injury; brain injury).

(c) Proposed staffing, including qualifications of the medical director, a description of staffing appropriate for any specialty program, and a discussion of the training and experience requirements for all staff who will provide comprehensive medical rehabilitation inpatient services.

(d) A plan for recruiting staff, showing expected sources of staff.

(e) Expected sources of patient referrals.

(f) Projected number of comprehensive medical rehabilitation inpatient services patient days by payer type, including Medicare, Medicaid, private insurance, self-pay and charity care patient days for the first 2 years of operation after completion of the proposed project.

(g) Admission policies of the facility with regard to charity care patients.

(9) Applications from Licensed Providers of Comprehensive Medical Rehabilitation Inpatient Services. A facility providing licensed comprehensive medical rehabilitation inpatient services seeking certificate of need approval for additional comprehensive medical rehabilitation inpatient beds shall provide the following information in its certificate of need application in addition to the information required by subsection (8):

(a) Number of comprehensive medical rehabilitation inpatient services admissions and patient days for the 12-month period ending 6 months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

(b) Number of comprehensive medical rehabilitation inpatient services patient days by payer type, including Medicare, Medicaid, private insurance, self-pay and charity care patient days, for the 12-month period ending 6 months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

(c) Gross revenues by payer source for the 12-month period ending 6 months prior to the beginning date of the quarter of the publication of the fixed bed need pool.

(d) Current staffing.

(e) Current specialty inpatient rehabilitation services, if any (e.g. spinal cord injury; brain injury).

(10) Utilization Reports. Facilities providing licensed comprehensive medical rehabilitation inpatient services shall provide utilization reports to the agency or its designee, as follows:

(a) Within 45 days after the end of each calendar quarter, facilities shall provide a report of the number of comprehensive medical rehabilitation inpatient services discharges and patient days which occurred during the quarter.

(b) Within 45 days after the end of each calendar year, facilities shall provide a report of the number of comprehensive medical rehabilitation inpatient days which occurred during the year, by principal diagnosis coded consistent with the International Classification of Disease (ICD-9).

(11) Applicability of this Amended Rule. This amended rule shall not be applied to applications that are pending final agency action as of the effective date of the rule, but shall be applied in the first review cycle commencing subsequent to the effective date of this rule.