Long Term Acute Care Hospital Bed Projects

Section 1110.265  Long Term Acute Care Hospital Bed Projects a)         Introduction 1)         This Section applies to projects involving Long Term Acute Care Hospital (LTACH) services. Applicants proposing to establish, expand or modernize an LTACH category of service shall comply with the applicable subsections of this Section, as follows: PROJECT TYPE REQUIRED REVIEW CRITERIA Establishment of Services or Facility (b)(1) − Planning Area Need – 77 Ill. Adm. Code 1100 (formula calculation ) (b)(2) − Planning Area Need – Service to Planning Area Residents (b)(3) − Planning Area Need – Service Demand − Establishment of Category of Service (b)(5) − Planning Area Need − Service Accessibility (c)(1) − Unnecessary Duplication of Services (c)(2) − Maldistribution (c)(3) − Impact of Project on Other Area Providers (e) − Staffing Availability (f) − Performance Requirements (g) − Assurances Expansion of Existing Services (b)(2) − Planning Area Need – Service to Planning Area Residents (b)(4) − Planning Area Need – Service Demand – Expansion of Category of Service (e) − Staffing Availability (f) − Performance Requirements (g) − Assurances Category of Service Modernization (d)(1) − Deteriorated Facilities (d)(2) & (3) − Documentation (d)(4) − Occupancy (f) − Performance Requirements 2)         If the proposed project involves the replacement of a hospital or service on-site, the applicant shall comply with the requirements listed in subsection (a)(1) (Category of Service Modernization) plus subsection (g) (Assurances). 3)         If the proposed project involves the replacement of a hospital or service on a new site, the applicant shall comply with the requirements of subsection (a)(1) (Establishment of ASTC Facility or Additional ASTC Service). 4)         If the proposed project involves the replacement of a hospital or service (onsite or new site), the number of beds being replaced shall not exceed the number justified by historical occupancy rates for each of the latest 2 years, unless additional beds can be justified per the criteria for Expansion of Existing Services. 5)         If the proposed project involves the conversion of existing acute care beds to LTACH services, the applicant shall comply with the requirements of subsection (a)(1) (Establishment of ASTC Facility or Additional ASTC Service), as well as requirements in subsection (b)(6) (Conversion of Existing General Acute Care Beds). b)         Planning Area Need − Review Criteria The applicant shall document that the number of LTACH beds to be established or added is necessary to serve the planning area's population, based on the following: 1)         77 Ill. Adm. Code 1100 (Formula Calculation) A)        The number of LTACH beds to be established is in conformance with the projected bed deficit specified in 77 Ill. Adm. Code 1100, as reflected in the latest updates to the Inventory. B)        The number of LTACH beds proposed shall not exceed the number of the projected deficit, to meet the health care needs of the population served, in compliance with the occupancy standard specified in 77 Ill. Adm. Code 1100. 2)         Service to Planning Area Residents A)        Applicants proposing to establish or add beds shall document that the primary purpose of the project will be to provide necessary health care to the residents of the area in which the proposed project will be physically located (i.e., the planning or geographical service area, as applicable), for each category of service included in the project. B)        Applicants proposing to add beds to an existing LTACH service shall provide patient origin information for all admissions for the last 12-month period, verifying that at least 75% of admissions were residents of the area.  For all other projects, applicants shall document that at least 75% of the projected patient volume will be from residents of the area. C)        Applicants proposing to expand an existing LTACH service shall submit patient origin information by zip code, based upon the patient's legal residence (other than a health care facility). 3)         Service Demand – Establishment of LTACH Service The number of beds proposed to establish a new category of hospital bed service is necessary to accommodate the service demand experienced annually by the existing applicant facility over the latest 2-year period, as evidenced by historical and projected referrals, or, if the applicant proposes to establish a new hospital, the applicant shall submit projected referrals.  The applicant shall document subsection (b)(3)(A) and either subsection (b)(3)(B) or (C). A)        Historical Referrals If the applicant is an existing facility, the applicant shall document the number of referrals to other facilities, for each proposed category of hospital service, for each of the latest 2 years.  Documentation of the referrals shall include patient origin by zip code, name and specialty of referring physician, and name and location of the recipient hospital. B)        Projected Referrals An applicant proposing to establish a category of service or establish a new hospital shall submit the following: i)          Physician referral letters that attest to the physician's total number of patients (by zip code of residence) who have received care at existing LTACH facilities located in the area or had a length of stay of over 25 days in a general acute care hospital and were considered to be LTACH candidates, annually over the latest 2-year period prior to submission of the application; and an estimate as to the number of patients that will be referred to the applicant's facility; ii)         An estimated number of patients the physician will refer annually to the applicant's facility within a 24-month period after project completion.  The anticipated number of referrals cannot exceed the physician's documented historical caseload; iii)        Each referral letter shall contain the physician's notarized signature, the typed or printed name of the physician, the physician's office address and the physician's specialty; and iv)        Verification by the physician that the patient referrals have not been used to support another pending or approved CON application for the subject services. C)        Projected Service Demand − Based on Rapid Population Growth If a projected demand for service is based upon rapid population growth in the applicant facility's existing market area (as experienced annually within the latest 24-month period), the projected service demand shall be determined as follows: i)         The applicant shall define the facility's market area based upon historical patient origin data by zip code or census tract; ii)        Population projections shall be produced, using, as a base, the population census or estimate for the most recent year, for county, incorporated place, township or community area, by the U.S. Census Bureau or IDPH; iii)       Projections shall be for a maximum period of 10 years from the date the application is submitted; iv)       Historical data used to calculate projections shall be for a number of years no less than the number of years projected; v)        Projections shall contain documentation of population changes in terms of births, deaths and net migration for a period of time equal to, or in excess of, the projection horizon; vi)       Projections shall be for total population and specified age groups for the applicant's market area, as defined by HFSRB, for each category of service in the application; and vii)      Documentation on projection methodology, data sources, assumptions and special adjustments shall be submitted to HFSRB. D)        Type of Patients The applicant shall identify the type of patients that will be served by the project by providing the anticipated diagnosis (by DRG classification) for anticipated admissions to the facility. The applicant shall also indicate the types of service (e.g., ventilator care, etc.) to be provided by the project. 4)         Service Demand – Expansion of Bed Category of Service The number of beds to be added for each category of service is necessary to reduce the facility's experienced high occupancy and to meet a projected demand for service.  The applicant shall document subsection (b)(4)(A) and either subsection (b)(4)(B) or (C): A)        Historical Service Demand i)          An average annual occupancy rate that has equaled or exceeded occupancy standards for the category of service, as specified in 77 Ill. Adm. Code 1100, for each of the latest 2 years. ii)         If patients have been referred to other facilities in order to receive the subject services, the applicant shall provide documentation of the referrals, including:  patient origin by zip code; name and specialty of referring physician; and name and location of the recipient hospital, for each of the latest 2 years. B)        Projected Referrals The applicant shall provide the following: i)          Physician referral letters that attest to the number of patients (by zip code of residence) that have received care at existing LTACH facilities located in the area or had a length of stay of over 25 days in a general acute care hospital and were considered to be LTACH candidates, during the 12-month period prior to submission of the application; ii)         An estimated number of patients the physician will refer annually to the applicant's facility within a 24-month period after project completion.  The anticipated number of referrals cannot exceed the physician's documented historical caseload.  The percentage of project referrals used to justify the proposed expansion cannot exceed the historical percentage of applicant market share, within a 24-month period after project completion; iii)        Each referral letter shall contain the physician's notarized signature, the typed or printed name of the physician, the physician's office address and the physician's specialty; and iv)        Verification by the physician that the patient referrals have not been used to support another pending or approved CON application for the subject services. C)        Projected Service Demand – Based on Rapid Population Growth If a projected demand for service is based upon rapid population growth in the applicant facility's existing market area (as experienced annually within the latest 24-month period), the projected service demand shall be determined as follows: i)          The applicant shall define the facility's market area based upon historical patient origin data by zip code or census tract; ii)         Population projections shall be produced, using, as a base, the population census or estimate for the most recent year, for county, incorporated place, township or community area, by the U.S. Census Bureau or IDPH; iii)        Projections shall be for a maximum period of 10 years from the date the application is submitted; iv)        Historical data used to calculate projections shall be for a number of years no less than the number of years projected; v)         Projections shall contain documentation of population changes in terms of births, deaths and net migration for a period of time equal to or in excess of the projection horizon; vi)        Projections shall be for total population and specified age groups for the applicant's market area, as defined by HFSRB, for each category of service in the application; and vii)       Documentation on projection methodology, data sources, assumptions and special adjustments shall be submitted to HFSRB. 5)         Service Accessibility The number of beds being established or added for each category of service is necessary to improve access for planning area residents.  The applicant shall document the following: A)        Service Restrictions The applicant shall document that at least one of the following factors exists in the planning area: i)          The absence of the proposed service within the planning area; ii)         Access limitations due to payor status of patients, including, but not limited to, individuals with health care coverage through Medicare, Medicaid, managed care or charity care; iii)        Restrictive admission policies of existing providers; iv)        The area population and existing care system exhibit indicators of medical care problems, such as an average family income level below the State average poverty level, high infant mortality, or designation by the Secretary of Health and Human Services as a Health Professional Shortage Area, a Medically Underserved Area, or a Medically Underserved Population; v)         For purposes of this subsection (b)(5) only, all services within the established radii outlined in 77 Ill. Adm. Code 1100.510(d) meet or exceed the utilization standard specified in 77 Ill. Adm. Code 1100. B)        Supporting Documentation The applicant shall provide the following documentation, as applicable, concerning existing restrictions to service access: i)          The location and utilization of other planning area service providers; ii)         Patient location information by zip code; iii)        Independent time-travel studies; iv)        A certification of waiting times; v)         Scheduling or admission restrictions that exist in area providers; vi)        An assessment of area population characteristics that document that  access problems exist; vii)       Most recently published IDPH Hospital Questionnaire. 6)         Conversion of Existing General Acute Care Beds – Review Criterion An applicant proposing to establish a Long Term Acute Care Hospital category of service through the conversion of existing general acute care beds shall: A)        Address Section 1110.30 for discontinuation of categories of service; B)        Identify modifications in scope of services or elimination of clinical service areas, not covered in Section 1110.290 (e.g., Emergency Department Classification, Surgical Services, Outpatient Services, etc.); C)        Submit a statement as to whether the following clinical service areas are to be available to the general population (non-LTACH): operating rooms, surgical procedure rooms, diagnostic services, therapy services (physical, occupational, speech, respiratory) and other outpatient services; and D)        Document that changes in clinical service areas will not have an adverse impact upon the health care delivery system.  An applicant shall document that a written request for information on any adverse impact was received by all hospitals within the established radii outlined in 77 Ill. Adm. Code 1100.510(d), and that the request included a statement that a written response be provided to the applicant no later than 15 days after receipt.  Failure by an existing facility to respond to the applicant's request for information within the prescribed 15-day response period shall constitute a nonrebuttable assumption that the existing facility will not be adversely impacted. c)         Unnecessary Duplication/Maldistribution − Review Criteria 1)         The applicant shall document that the project will not result in an unnecessary duplication.  The applicant shall provide the following information: A)        A list of all zip code areas that are located, in total or in part, within the established radii outlined in 77 Ill. Adm. Code 1100.510(d) of the project's site; B)        The total population of the identified zip code areas (based upon the most recent population numbers available for the State of Illinois population); and C)        The names and locations of all existing or approved health care facilities located within the established radii outlined in 77 Ill. Adm. Code 1100.510(d) of the project site that provide the categories of bed service that are proposed by the project. 2)         The applicant shall document that the project will not result in maldistribution of services.  Maldistribution exists when the identified area (within the planning area) has an excess supply of facilities, beds and services characterized by such factors as, but not limited to: A)        A ratio of beds to population that exceeds one and one-half times the State average; B)        Historical utilization (for the latest 12-month period prior to submission of the application) for existing facilities and services that is below the occupancy standard established pursuant to 77 Ill. Adm. Code 1100; or C)        Insufficient population to provide the volume or caseload necessary to utilize the services proposed by the project at or above occupancy standards. 3)         The applicant shall document that, within 24 months after project completion, the proposed project: A)        Will not lower the utilization of other area providers below the occupancy  standards specified in 77 Ill. Adm. Code 1100; and B)        Will not lower, to a further extent, the utilization of other area hospitals that are currently (during the latest 12-month period) operating below the occupancy standards. d)         LTACH Modernization 1)         If the project involves modernization of an LTACH category of service, the applicant shall document that the inpatient bed areas to be modernized are deteriorated or functionally obsolete and need to be replaced or modernized due to such factors as, but not limited to: A)        High cost of maintenance; B)        Noncompliance with licensing or life safety codes; C)        Changes in standards of care (e.g., private versus multiple bed rooms); or D)        Additional space for diagnostic or therapeutic purposes. 2)         Documentation shall include the most recent: A)        IDPH CMMS inspection reports; and B)        The Joint Commission reports. 3)         Other documentation shall include the following, as applicable to the factors cited in the application: A)        Copies of maintenance reports; B)        Copies of citations for life safety code violations; and C)        Other pertinent reports and data. 4)         Projects involving the replacement or modernization of a category of service or hospital shall meet or exceed the occupancy standards for the categories of service, as specified in 77 Ill. Adm. Code 1100. e)         Staffing Availability − Review Criterion The applicant shall document that relevant clinical and professional staffing needs for the proposed project were considered and that licensure and The Joint Commission staffing requirements can be met.  In addition, the applicant shall document that necessary staffing is available by providing letters of interest from prospective staff members, completed applications for employment, or a narrative explanation of how the proposed staffing will be achieved. f)         Performance Requirements 1)         Bed Capacity Minimum An applicant shall document that the project will result in a facility capacity of at least 50 LTACH beds located in an MSA and 25 LTACH beds in a non-MSA. 2)         Length of Stay A)        An applicant proposing to add beds to an existing service shall document that the average length of stay (ALOS) for the subject service is consistent with the planning area's 3-year ALOS. B)        Documentation shall consist of the 3-year ALOS for all hospitals within the planning area (as reported in the Annual Hospital Questionnaire). C)        An applicant whose existing services have an ALOS exceeding 125% of the ALOS for area providers shall document that the severity or type of illness treated at the applicant facility is significantly higher than the planning area average.  Documentation shall be provided from CMMS or other objective records. D)        An applicant whose existing services have an ALOS lower than the planning area ALOS shall submit an explanation as to the reasons for the divergence. 3)         Be certified by Medicare as a Long Term Acute Care Hospital within 12 months after the date of project completion. g)         Assurances The applicant representative who signs the CON application shall submit a signed and dated statement attesting to the applicant's understanding that, within 30 months of operation after the project completion, the applicant will achieve and maintain the occupancy standards specified in 77 Ill. Adm. Code 1100 for each category of service involved in the proposal.