|
DOH |
STATE OF NEW YORK DEPARTMENT OF HEALTH 433 River Street, Suite 303 Troy, New York 12180-2299 |
Antonia
C. Novello, M.D., M.P.K., Dr. Ph.H. Dennis
P. Whalen
Commissioner Executive
Deputy Commissioner
October 14, 2005
Mr. Scott
F. Sittig RE: 051147-B
Executive
Director
His
Branches, Inc.
His
Branches, Inc.
(Monroe
County)
342 Arnett
Boulevard, Suite No. 3
Rochester, New York 14619
Dear Mr. Sittig:
Review of the
above application has revealed the need for the additional information
requested in the enclosure from the Bureau of Financial Analysis. In preparing
answers to the questions, please repeat each question and then provide the
answer. Please submit your response within 15 days of the date of this letter
in accordance with 10 NYCRR 71 0.3(a), as follows:
1. one copy to the
Bureau of Financial Analysis, New York State Department of Health, Hedley Park
Place, 6th Floor, 433 River Street, Troy, New York 12180-2299.
2. an original and
eight copies of your response to Ms. Diane Smith, Director, Information and
Technology Services Group, New York State Department of Health, Hedley Park
Place, 6th. Floor, 433 River Street, Troy, New York, 12180-2299
Processing of your
application by the Bureau of Financial Analysis cannot be completed until the
information is received and reviewed. Also, if this project requires review by
the State Hospital Review and Planning Council, such review may have to be
delayed if the requested information is not received promptly (particularly if
the Bureau of Financial Analysis does not receive a separate copy).
Accordingly, you are encouraged to submit the response at your earliest
opportunity. In this regard, be advised that a single faxed response to this
request does not constitute a full and complete response.
If you have any
question on the information being requested, please contact the individual
identified on the enclosure.
Sincerely,
Charles P. Abel, Director
Bureau
of Financial Analysis
October 14, 2005
051 147-B
His Branches, Inc.
(Monroe County)
The Bureau of
Financial Analysis has prepared the following questions. In preparing your response to this letter, please be sure to
demonstrate how your project is responsive to the goals and objectives of the
Commission on Health Care Facilities for the 21St Century of promoting
stability and efficiency in the delivery of high quality and cost effective
care. Specifically, where appropriate, your responses should demonstrate how
your proposal is consistent with the concept of appropriately sized capacity
considering individual and regional resources and needs, is a collaboration at
the community level, avoids duplication of services, provides access to
underserved populations, and is all
delivered in an affordable and cost
effective manner. If additional
information is needed, please
contact Whitney Reed at (518) 402-0953.
1. Provide a revised
Schedule 1A reflective of the legal entity that will operate the facility (the
proposed operator).
2. Provide the 2003
and 2004 certified financial statements for His Branches, Inc. If applicable,
address the reason(s) for any losses and step(s) implemented to improve
operations.
3. Working capital
requirements are set at two months’ of third year expenses, of which a minimum
of 50% must be provided as equity. Document all sources of equity. If the
remaining 50% will be borrowed, provide a letter of interest from the intended
source of working capital financing, to include an estimate of principal, term
and interest rate.
4. Submit a pro forma
balance sheet, reflective of the first day subsequent to approval. Provide a
line by line comparison between the pro forma balance sheet and the most
recently available certified financial statements. Provide all assumptions utilized
in preparation of the pro forma balance sheet, including the required working
capital.
5. Provide an interim
financial summary for His Branches, lnc, for current year operations.
6. Provide an updated
project cost breakdown based on a reasonably attainable construction start
date.
7. Provide an updated
financing plan based on any changes in project cost, including documentation
and/or status of fundraising efforts.
8. Revenues
and expenses should be in 2005 dollars, do not trend rates or inflation. Please
resubmit as necessary. Include supporting documentation for the rates assumed
for all payors, particularly the Medicaid rate. Year three average cost per
visit should be the same or less than year one average cost, based on an
increase in utilization.
9. Provide
clarification of depreciation expense calculation.
10. Medicaid
utilization and revenue should take into consideration Medicaid Managed Care
penetration based on the Mandatory Medicaid Managed Care Phase In Schedule for
New York State. For further information, contact your local Social Service
district. Provide all assumptions and justification for proposed Medicaid
Managed Care utilization and revenue.
11. Clarify
the financial and social/medical benefits of His Branches, Inc, becoming an
Article 28 facility.
12. Complete
the enclosed representative governance questionnaire.
Governance Questionnaire
CON # _____________
FACILITY NAME:
_________________________________________
ADDRESS: _________________________________________
_________________________________________
_________________________________________
Please respond to the following questions with respect to the CON
application referenced above:
1. a. Is the applicant, or any of its owners,
employed by, an owner, officer, director, or manager of, in any other way affiliated with, or acting on
behalf or for the benefit of, an outside entity which will be involved with
(including through a lease, contract or agreement), or benefit from, the
ownership or operation of the proposed facility?
___ No - skip to Question #lb.
___ Yes - identify the outside entity and the nature
of the relationship: ________________________
b. Are there
any contractual restrictions, existing or proposed, on the ability of the
owners of the applicant to assign, transfer or sell their ownership interests
or voting rights in the applicant?
___ No - skip to Question #2.
___ Yes - provide copies of the existing or proposed
agreements.
2. Does this
proposal include a consulting and/or administrative services agreement?
___
No - skip to Question #3.
___ Yes - attach a copy, if not already submitted with
the CON, and continue with questions in this section.
a. What are the services to be provided
under the agreement? ________________________
_______________________________________________________________________
b. What is the relationship between the
applicant/operator and the consultant? __________
_______________________________________________________________________
c. Who/what owns the consultant entity?
________________________________________
d. Who will manage the subject facility on a
day-to-day basis? _______________________
e. Who employs the facility manager?
__________________________________________
f. Will there be any subcontracts or
assignments with other entities?
___ No
___ Yes - attach copies and define:
_________________________________________
g. What percentage of facility revenues flow
to the consultant? _______________________
h. Is the
consultant also: an equipment lessor for the facility? ___ No
___ Yes
a
real property lessor for the facility? ___ No
___ Yes
i. Who is responsible for financial
decisions? By whom is this person employed (facility or consultant)?
_____________________________________________________________
3. Will another entity
provide financing for this CON project?
___ No
___ Yes - complete below
a. Define lender and its relationship to the
applicant and consultant. __________________
_______________________________________________________________________
Completed
by: ______________________ Signature:____________________________ Date:________
Please
mail your response to Bureau of Project Management, NYS Department of Health, 433 River Street, 6th Floor,
Troy, NY 12180. Thank you.