DOCKET NO: BOARD MEETING: PROJECT NO: PROJECT COST: A - 11 December 20-21, 2006 06-069 Original: $ 2,754,928 Current: FACILITY NAME: CITY: Midwest Endoscopy Center NapervilleTYPE OF PROJECT: Substantive HSA: VIIPROJECT DESCRIPTION: The applicant proposes to establish a limited-specialty,freestanding ambulatory surgical treatment center (“ASTC”) with two operating rooms(“ORs”) and 12 recovery stations.
STATE AGENCY REPORT Midwest Endoscopy Center, LLC, d/b/a Midwest Endoscopy Center Naperville, Illinois Project #06-069I. The Proposed Project The applicant proposes to establish a limited-specialty, freestanding ambulatory surgical treatment center (“ASTC”) with two operating rooms (“ORs”) and 12 recovery stations. The ASTC will only perform gastroenterology procedures. The facility will contain 5,941 gross square feet (“GSF”) in new construction. The total estimated project cost is $2,754,928.II. Summary of Findings A. The State Agency finds the proposed project does not appear to be in conformance with the provisions of Part 1110. B. The State Agency finds the proposed project does not appear to be in conformance with the provisions of Part 1120.III. General Information The applicant is Midwest Endoscopy Center, LLC, d/b/a Midwest Endoscopy Center. The ASTC will be located in Naperville (HSA VII). There are 17 facilities providing outpatient surgical service within 30 minutes travel time of the applicant’s proposed facility. This is a substantive project, which is subject to both a Part 1110 and Part 1120 review. An opportunity for a public hearing was provided; however, no hearing was requested. Project obligation is contingent upon permit issuance and the appropriate documentation was submitted. The anticipated project completion date is February 28, 2008.IV. The Proposed Project – Details The applicant proposes to establish a limited-specialty ASTC with two ORs and 12 recovery stations. The ASTC will be established in 5,941 GSF located at 1245
State Agency ReportProject #06-069Page 2 of 16 Rickert Drive in Naperville. The facility will perform gastroenterology procedures.V. Project Costs and Sources of Funds The total project cost is $2,754,928. The applicant will fund the project with cash and securities, a bank loan and other funds and sources. The State Agency notes that Other Funds and Sources includes working capital related to the project (per 77 IAC 1120.110(a)(12). Table One displays the project’s cost and sources of funds information. TABLE ONE Use of Funds Amount Site Preparation 188,110 New Construction 1,620,807 Contingencies 90,448 Architectural/Engineering Fees 170,414 Consulting and Other Fees 30,275 Movable Equipment 600,000 Net Interest Expense During Construction 54,874 TOTAL $ 2,754,928 Source of Funds Amount Cash and Securities 136,590 Mortgage 2,018.338 Other Funds and Sources 600,000 TOTAL $ 2,754,928VI. Review Criteria – Non-Hospital Based Ambulatory Surgery A. Criterion 1110.1540(a) – Scope of Services Provided The applicant must document the surgical specialties that will be provided by the proposed project and that 250 procedures will be performed for at least three of the surgical specialties proposed. The applicant proposes a limited-specialty ASTC, which will provide only gastroenterology procedures. The applicant submitted one physician
State Agency ReportProject #06-069Page 3 of 16 referral letter (from Suburban Gastroenterology, Ltd.) identifying 1,451 referrals. These referrals were made in the past 12 months to Edward Hospital (Naperville) and The Center for Surgery (Naperville). The applicant also identified 1,949 procedures that were performed in physicians’ offices. The State Agency notes the procedures performed in physicians’ offices cannot be counted towards the total number of projected referrals for the new facility (as per the requirement of 77 IAC 1110.1540(c)(2)). Table Two displays the referrals provided in the application and the patient volume by specialty. From the information provided, it appears the applicant has demonstrated that at least 250 procedures will be performed in the identified surgical specialty. TABLE TWO Specialty Projected Patient Volume Gastroenterology 1,451 THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. B. Criterion 1110.1540(b) – Target Population The State Board has not established planning areas for ASTCs. Per this criterion, the applicant must provide evidence that “the intended geographic service area shall be no less than 30 minutes and no greater than 60 minutes travel time (under normal driving conditions) from the facility’s site.” The applicant provided a map outlining the geographic service area (“GSA”). The applicant proposes to serve the population within 30 minutes travel time within all boundaries of the proposed facility. It appears the applicant has met the requirements of this criterion. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE CRITERION.
State Agency ReportProject #06-069Page 4 of 16 C. Criterion 1110.1540(c) – Projected Patient Volume The applicant must document the projected patient volume for each specialty proposed. Documentation must include physician referral letters which contain the following information: 1) The number of referrals anticipated annually for each specialty; 2) For the past 12 months, the name and location of health care facilities to which patients were referred, including the number of patients referred for each surgical specialty by facility; 3) A statement by the physician that the information contained in the referral letter is true and correct to the best of his/her information and belief; and 4) The typed or printed name and address of the physician, his/her specialty and his/her notarized signature. The applicant submitted one physician referral letter, which contained the information required by the criterion. Table Three provides a breakdown of where surgical procedures were performed. TABLE THREE Facility Procedures / Percentage Edward Hospital 634 procedures, or 44% of total procedures performed Center for Surgery 817 procedures, or 56% of total procedures performed The applicant states that the estimated time per procedure is 80 minutes, or 1.33 hours. Based on this estimation and the anticipated referrals, the applicant can justify 1,930 hours of surgery for the 1,451 cases. This documents the need for two ORs, which is what the applicant proposed. As a result, a positive finding can be made. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. D. Criterion 1110.1540(d) – Treatment Room Need Assessment The applicant must document that the number of ORs are needed to serve the projected volume. The applicant anticipates 1,451 cases during the first year of operation. According to the applicant, the average procedure time, including room “turnover”, is 80 minutes. The applicant indicates the average procedure time was based upon historical data provided by
State Agency ReportProject #06-069Page 5 of 16 the participating physicians. Table Four displays the need assessment for treatment rooms based upon estimated procedures and surgery time. TABLE FOUR Procedures Total Hours for Procedures Standard Hours Per OR ORs Justified 1,451 1,930 1,500 2 Based on the State standard of 1,500 hours per OR, and if the projected patient volume materializes, the applicant’s proposed number of ORs is appropriate. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. E. Criterion 1110.1540(e) – Impact on Other Facilities The applicant must document the impact the proposed facility will have on the outpatient surgical capacity in the proposed GSA. The applicant stated (application pages 18-19) that only 12 facilities existed within a 30 minute travel time of the proposed site. To verify the applicant’s information, the State Agency performed a Map Quest review and determined there are 17 facilities within a 30 minute travel time that provide outpatient surgical service. Table Five displays the distance and travel times for these facilities. TABLE FIVE Facility City Travel Time (minutes) Distance (miles)Naperville Surg Ctr Naperville 2 200 yardsEdward Hospital Naperville 5 3Castle Surgicenter Aurora 12 6Rush-Copley Med Ctr Aurora 12 6Kendall Pointe Surg Ctr Oswego 13 9Cen DuPage Hospital Winfield 21 13Good Samaritan Hosp Downers Grove 21 14Midwest Ctr for Day Surg Downers Grove 21 15The Center for Surgery Naperville 15 7DuPage Ortho Surg Ctr Warrenville 15 7Bolingbrook Med Ctr Bolingbrook 18 8Dreyer Amb Surg Ctr Aurora 22 15Salt Creek Surg Ctr Westmont 26 14Chicago Prostate Cancer Surg Ctr Westmont 26 17DuPage Med Grp Surg Ctr Lombard 28 13Oak Brook Surg Ctr Oak Brook 30 14Northeast DuPage Surg Ctr Addison 30 22
State Agency Report Project #06-069 Page 6 of 16 To determine the potential impact this project would have on existing providers, the State Agency compiled the 2005 surgical utilization data for the 17 identified facilities. This data is presented in Table Six and was provided by IDPH profiles. As seen in Table Six, there is excess surgical capacity at five ASTCs, including: Castle Surgery Center, Kendall Point Surgery Center, Midwest Center for Surgery, Naperville Surgical Center and Northeast DuPage Surgery Center. It is noted these five ASTCs are designated as multi- specialty facilities. Four facilities (Kendall Point Surgery Center, Midwest Center for Surgery, Naperville Surgical Centre and Northeast DuPage Surgery Center) provide the gastroenterology service. The other facility, Castle Surgery Center, does not provide this service. However since it is a multi-specialty ASTC, it could establish this service without a CON. TABLE SIX Hospital Data Hours of Total Number Equivalent ORs Justified per Excess Facility Location Outpatient Hours of of ORs Outpatient ORs(1) State Standard(2) ORs Surgery SurgeryBolingbrook Medical Ctr (3) Bolingbrook NA NA 6 NA NA NACentral DuPage Hospital Winfield 16,324 32,136 21 11 22 0Edward Hospital Naperville 13,329 27,088 16 9 19 0Good Samaritan Hospital D. Grove 7,867 21,341 10 6 15 0Rush-Copley Medical Center Aurora 19,406 10,279 12 13 13 0 ASTC Data Number ORs Justified per Excess Facility Location Specialty Hours of Surgery of ORs State Standard ORsCastle Surgery Center Aurora Multi 2 1,362 1 1Chicago Prostate Surg Ctr (4) Westmont Limited 2 NA NA NADreyer Ambulatory Surg Ctr Aurora Multi 4 7,172 5 0DuPage Med Grp Surg Ctr (5) Lombard Multi 5 NA NA NADuPage Ortho Surg Ctr (6) Warrenville Limited 2 NA NA NAKendall Point Surgery Center Oswego Multi 3 876 1 2Midwest Center for Surgery D. Grove Multi 5 5,473 4 1Naperville Surgical Centre Naperville Multi 4 3,951 3 1Northeast DuPage Surg Ctr Addison Multi 4 2,751 2 2Oak Brook Surgical Center Oak Brook Multi 4 6,446 5 0Salt Creek Surgery Center (7) Westmont Multi 4 4,597 4 0The Center for Surgery Naperville Multi 8 16,808 12 01- Hours of Outpatient Surgery/1,500.2 - Total Hours of Surgery/1,5003 – Project #03-095, approved on 11/1/04; required completion date 10/21/08.4 – Project #04-027, approved on 3/3/05 to establish a limited-specialty ASTC for urology procedures; required completion date 11/30/06.5 - Project #03-022, approved on 8/19/03 to establish a multi-specialty ASTC; project completed on 1/4/06.6 – Project #03-006, approved on 2/18/04 to establish a limited-specialty ASTC for orthopedic procedures; project completed on 3/20/06.7 – Facility now known as Salt Creek Surgery Center.The applicant considers the facilities listed in bold and italics as not being within 30 minutes travel time of the proposed facility.
State Agency ReportProject #06-069Page 7 of 16 In addition, three ASTCs (Chicago Prostate Surgical Center, DuPage Medical Group Surgical Center and DuPage Orthopedic Surgery Center) were not operational in 2005. The State Agency notes that both Chicago Prostate Surgical Center and DuPage Orthopedic Surgery Center are designated as limited-specialty ASTCs. Thus, these facilities could not establish the gastroenterology service without a CON. The other facility, DuPage Medical Group Surgery is designated as a multi-specialty ASTC and provides the gastroenterology service. Thus, this proposal’s potential impact on that facility is unknown. Further, Bolingbrook Medical Center will have six ORs when it is completed in October 2008. Since there is excess surgical capacity at existing providers which offer the surgical service proposed by the applicant, it appears the project may negatively impact area providers. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. F. Criterion 1110.1540(f) – Establishment of New Facilities This criterion states that an ASTC will be approved only if one of the following conditions exists: 1. There are no other ASTCs in the GSA under normal driving conditions; or 2. All existing ASTCs and hospital equivalent outpatient surgery rooms within the GSA are utilized at or above the 80% occupancy target; or 3. The applicant can document that the facility is necessary to improve access to care. Documentation shall consist of evidence that the facility will be providing services which are not currently available in the GSA, or that the existing underutilized services in the GSA have restrictive admission polices; or 4. The proposed project is a cooperative venture sponsored by two or more persons, at least one of which operates an existing hospital. There are 12 existing ASTCs in the GSA; three of which were not operational in 2005. Of the nine ASTCs that were operational in 2005, seven provided the gastroenterology service (which is the service proposed by the applicant). Also, these nine ASTCs are designated as multi-specialty. Thus, the remaining two ASTCs that do not provide the gasteoenterology service could establish the service without a CON. As a
State Agency ReportProject #06-069Page 8 of 16 result, the applicant cannot meet the requirements of (f)(1) of the criterion. As noted in Table Five, five ASTCs located in the GSA are not operating at target utilization. Further, one hospital (Bolingbrook Medical Center) is currently under construction with an anticipated completion date of October 2008. The surgical utilization is unknown for that facility. There are also three ASTCs which were not operational in 2005. Thus, the applicant cannot document compliance with the requirements of (f)(2) of the criterion. The service proposed by the applicant is currently provided in the GSA and no documentation was submitted to indicate that existing providers have restrictive admission policies. Thus, the applicant cannot meet the requirements of (f)(3) of the criterion. Finally, the project does not represent a co-operative venture with another facility. As a result, the applicant cannot meet the requirements of (f)(4) of the criterion. As noted in the rule, the applicant is required to meet one of the above- referenced conditions. Based on the information submitted and the data from IDPH’s 2005 hospital and ASTC profiles, it does not appear the applicant met any of the requirements of this criterion. As a result, a positive finding cannot be made. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. G. Criterion 1110.1540(g) – Charge Commitment The applicant states the proposed facility will maintain charges for the first two years of operation. Therefore, a positive finding can be made. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. H. Criterion 1110.1540(h) – Change in Scope of Service This criterion is not applicable as the project represents the establishment of a new facility. THE STATE AGENCY NOTES THE ABOVE CRITERION IS NOT APPLICABLE TO THIS PROJECT
State Agency ReportProject #06-069Page 9 of 16VII. General Review Criteria A. Criterion 1110.230(a) – Location This criterion requires the applicant to provide documentation (1) that the primary purpose of a proposed project is to provide care to residents of the planning area in which the facility will be located, and (2) that the location selected will not create a maldistribution of services. The applicant provided zip code data for the anticipated patient referrals and it appears a significant majority of the zip codes are within the GSA. It appears the ASTC will provide care to residents of the GSA. However, it appears the proposed facility will contribute to an existing maldistribution of service. Thus, a positive finding cannot be made. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE ABOVE CRITERION. B. Criterion 1110.230(b) - Background of Applicant The applicant provided licensure and certification information as required. The applicant certified it has not had any adverse actions within the past three years. It appears the applicant is fit, willing and able and has the qualifications, background and character to adequately provide a proper standard of healthcare service for the community. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION. C. Criterion 1110.230(c) - Alternatives The applicant must document the proposed project is the most effective or least costly alternative. The applicant considered the following options (application page 29): 1. Do nothing. The applicant states this option would have no cost but would not address the patients’ need for quick and convenient surgical service nor would it address physician need for a facility which allows them to maximize their ability to treat patients in a timely and effective manner.
State Agency ReportProject #06-069Page 10 of 16 2. Construct a facility as part of the physicians’ office which would not be separately licensed. According to the applicant, this option would achieve the goal of treating patients in a timely and efficient manner and allow physicians the ability to treat patients whose insurance requires that procedures be performed in a licensed setting. It would also limit the amount of equipment which could be used since the facility fee is necessary to cover these expenses. It is noted the applicant did not quantify a cost with this option. 3. Establish an ASTC in conjunction with the proposed new medical offices which the physicians are constructing. This option was chosen by the applicant because it meets all of the identified needs of physicians and patients. It allows for a timelier scheduling of procedures and allows physicians to have surgical blocks of time for their patients which allow them to be more efficient and minimizes cancellations and delays. As noted, excess surgical capacity exist in the GSA. Thus, the establishment of the proposed ASTC may add to this identified excess. Therefore, it appears a less costly alternative would be to utilize existing providers within the GSA. Also, the applicant did not provide a cost analysis for all stated alternatives as required by the criterion. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION. D. Criterion 1110.230(d) - Need for the Project The applicant is required to document that the project is needed. The State Board has not determined need for this category of service; therefore, the applicant must document that the proposed project will serve a population group in need of the services proposed and that insufficient service exists to meet the need. The applicant referred to a physician letter committing cases to document need for the project. As referenced, it appears there is excess surgical capacity with existing providers in the GSA to accommodate the
State Agency ReportProject #06-069Page 11 of 16 procedures proposed for the applicant’s facility. Therefore, it does not appear need for the facility has been documented. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION. E. Criterion 1110.230(e) - Size of the Project The total GSF of the proposed ASTC will be 5,941 GSF. The project will consist of two ORs and 12 recovery stations. Based upon the State standard of 2,750 GSF per OR and 180 GSF per recovery station, the applicant can justify 6,940 GSF. The 5,941 GSF proposed is within the State standard. The applicant projects 1,451 procedures will be performed in the first year of operation. This volume projection is based upon the physician referral letter. If the applicant’s projected workload materializes, it appears the ORs will be appropriately utilized THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION.VIII. Review Criteria - Financial Feasibility A. Criterion 1120.210(a) - Financial Viability This criterion states certain ratios be met as an indication of financial viability for applicants that do not have a bond rating of “A” or better. If the viability ratios are not met, applicants are to address a variance that documents another organization will assume the legal responsibility of meeting any debt obligations should the applicant default. 1. Viability Ratios Table Seven provides financial ratio information for the applicant. The State Agency notes the applicant is a newly formed entity. Thus, historic financial information is not available.
State Agency ReportProject #06-069Page 12 of 16 TABLE SEVEN Midwest Endoscopy Center, LLC State Historical Projected Ratios Standard 2003 2004 2005 2008 Current Ratio >=1.5 NA NA NA 26.5 Net Margin Percentage >=2.5% NA NA NA 42.3% Percent Debt to Total Capitalization <=80% NA NA NA 54% Projected Debt Service Coverage >=1.50 NA NA NA 5.1 Days Cash on Hand >=75 NA NA NA 156 Cushion Ratio >=5 NA NA NA 2.3 As seen in Table Seven, the applicant meets all of the ratio requirements with the exception of the Cushion Ratio. This ratio is an indication of the amount of cash, short-term investment and unrestricted long-term investment remaining after paying all fixed-debt expenses (annual principal and interest payments). The applicant did not address the variance, which allows another entity to document it would assume the legal responsibility of meeting debt obligations. Since the applicant does not meet all the ratio requirements and did not address the variance, a positive finding cannot be made. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION. B. Criterion 1120.210(b) - Availability of Funds The applicant documented that sufficient resources are available to fund the project and related costs. The project will be funded with $136,590 of cash and securities, $2,018,338 with a mortgage and $600,000 from other funds and sources. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION. C. Criterion 1120.210(c) - Start-Up Costs The applicant estimates start-up costs for the facility will be $255,010. This cost includes debt service for three months, initial supplies and expenses
State Agency ReportProject #06-069Page 13 of 16 for the first year of operation. Based on the information submitted, it appears funds are available to finance the start-up costs. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION.IX. Review Criteria - Economic Feasibility A. Criterion 1120.310(a) - Reasonableness of Financing Arrangements The applicant verified that all available cash and securities will be used prior to borrowing. Borrowing will be used because cash and equivalents must be retained in the balance sheet asset accounts so that the current ratio does not fall below 2.0. Further, the applicant documented that borrowing is less costly than the liquidation of existing investments and the existing investments can be converted to cash or used to retire debt within a 60-day period (if needed). THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE ABOVE REVIEW CRITERION. B. Criterion 1120.310(b) - Terms of Debt Financing The applicant provided the required documentation which states the financing chosen will be at the lowest net cost available or if a more costly form of financing is selected, that form is more advantageous due to such terms as prepayment privileges, no required mortgage, access to additional debt, term (years), financing costs, and other factors. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE REVIEW CRITERION. C. Criterion 1120.310(c) - Reasonableness of Project Cost Site Preparation – This cost is $188,110, which is 11% of new construction and contingencies. This appears high compared to the State standard of 5%. Under the standard, the applicant would be allowed $85,563 for this expense. The applicant’s proposed cost exceeds the standard by $102,547, or 120%. Table Eight displays the State Agency’s finding.
State Agency ReportProject #06-069Page 14 of 16 TABLE EIGHTProposed Site Preparation Costs State Standard Difference $188,110 $85,563 $102,547 New Construction Contracts and Contingencies – These costs are $1,711,255, or $288.04 per GSF. This appears high compared to the adjusted State standard of $269.56 per GSF. The applicant’s proposed cost exceeds the standard by $18.48 per GSF. Considering the total GSF proposed, the applicant exceeds the standard by $109,799, or 6.6%. Table Nine displays the State Agency’s finding. TABLE NINE Proposed Cost per GSF Adjusted State Standard per GSF Difference per GSF $288.04 $269.56 $18.48 Total Proposed Construction Cost State Standard Difference $1,711,255 $1,601,456 $109,799 Contingencies - The cost is $90,448, or 5.6% of construction. This appears reasonable compared to the State standard of 10%. Architects and Engineering Fees - These costs total $170,414, or 9.95% of construction and contingencies. This falls within the Capital Development Board’s fee structure of 4.65% - 11.0% that is utilized as the State standard. Consulting and Other Fees - These costs total $30,275. The State Board does not have a standard for this expense. Movable or Other Equipment - Equipment costs total $600,000, or $300,000 per OR. This appears reasonable compared to the adjusted State standard of $444,898 per OR. Net Interest Expense During Construction – This cost is $54,874. The State Board does not have a standard for this expense. THE STATE AGENCY FINDS THE PROPOSED PROJECT DOES NOT APPEAR TO BE IN CONFORMANCE WITH THE REVIEW CRITERION. D. Criterion 1120.310(d) - Projected Operating Costs The applicant projects $352.85 of direct annual operating cost per procedure. The State Board does not have a standard for these costs.
State Agency ReportProject #06-069Page 15 of 16 THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE REVIEW CRITERION. E. Criterion 1120.310(e) - Total Effect of the Project on Capital Costs The applicant projects $146.00 in capital costs per procedure. The State Board does not have a standard for these costs. THE STATE AGENCY FINDS THE PROPOSED PROJECT APPEARS TO BE IN CONFORMANCE WITH THE REVIEW CRITERION. F. Criterion 1120.310(f) - Non-Patient Related Services This criterion is not applicable.G:FACSAR2006-sar06-069.doc