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APPLICATION for CERTIFICATE OF NEED [Pursuant to U. S. Virgin Islands Code, Title 19, Part II, Chapter 15] "[Click here & type]" Name of Applicant Address of Applicant CERTIFICATION I, the undersigned, certify that to the best of my knowledge, information contained in this application is true and accurate. ____________________________________________________ Signature of Owner or Governing Body's Designee "[Click here & type]" Date GOVERNMENT OFTHE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH 9048 SUGAR ESTATE, ST. THOMAS, U. S. V. I. 00802 USVI CON Application – Page 2 of 17 DOH Form Revised 02/13/2024 SECTION I - PROJECT IDENTIFICATION (1) Legal name of the owner or operator of the proposed service or facility: "[Click here & type]" (2) Name of Contact Person (indicate whether person is Owner, Operator or Other): "[Click here & type]" (3) Address: "[Click here & type]" (4) Telephone Number: ("[Click & type area code]" ) "[Click & type number]" ext. "[Click & type extension]" (5) Fax Number: ("[Click & type area code]" )"[Click & type number]" (6) E-mail Address: "[Click & type E-Mail]" (7) Officers, Managers, Directors, Trustees and Affiliates: Name Office "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" "[Click & type name]" "[Click & type Office]" (8) Facility Type: "[Click & type]" (9) Total Project Cost: $"[Click & type]" Note: This cost should equal the total project cost reported on Page 12 (10) Estimated date project will commence: "[Click & type]" (11) Estimated date of substantial project completion: "[Click & type]" (12) Proposed hours of operation of the service: "[Click & type]" (13) Plans, if any, to make the services available during other hours: "[Click & type]" USVI CON Application – Page 3 of 17 DOH Form Revised 02/13/2024 SECTION II - PURPOSE AND SCOPE OF PROPOSED PROJECT (1) Problem(s) you are addressing in this project. "[Click & type]" (2) Achievable goals and objectives to solve the problem(s) identified in (1) above. (a) What will be accomplished as a result of the proposed project and the expected results. "[Click & type]" (b) An evaluation of alternative technologies and products for the services contemplated by your project, including: (i) Description of available technologies and products that you intend to utilize in connection with the project: "[Click & type]" (ii) Service capabilities of such products or technologies: "[Click & type]" (iii) Service capabilities of other comparable products or technologies that are not available from the product or technology you intend to utilize in connection with the project: "[Click & type]" (iv) Reasons that you chose the selected product or technology instead of other available technologies: "[Click & type]" (c) Evaluate the impact on the health care system of the service capabilities described above being unavailable: "[Click & type]" (d) Evaluate the availability of the service to members of the population, including a list of managed care organizations with which you maintain a contract or propose to contract: "[Click & type]" (e) Evaluate the affordability of the services to be offered by the project: "[Click & type]" (f) Evaluate the affordability of service capabilities that are not available through the proposed project, but which are available pursuant to alternative technologies and equipment described in (b) above: "[Click & type]" USVI CON Application – Page 4 of 17 DOH Form Revised 02/13/2024 (g) Evaluate the impact of the proposed project on the medically under serviced population: "[Click & type]" (h) Describe the innovative features of the proposed project: "[Click & type]" (3) Provide a management plan which specifies the actions, roles and capabilities of the individuals responsible for the management and operation of your services and/or programs. "[Click & type]" (4) Show a timetable outlining the process needed to effectuate the objectives stated above. "[Click & type]" USVI CON Application – Page 5 of 17 DOH Form Revised 02/13/2024 SECTION III - STANDARDS AND CRITERIA [ADDRESS THE APPLICABLE STANDARD FOR THE PROJECT UNDER REVIEW] Address all the standards and criteria that are applicable to the project under review. (Attach additional discussions, if needed.) "[Click & type]" USVI CON Application – Page 6 of 17 DOH Form Revised 02/13/2024 SECTION IV - PROJECT COMPONENTS [If any portion of the following sections have no bearing on the project under consideration, state "Not Applicable". Attach additional discussions as needed.] PART A - DEMONSTRATION OF PUBLIC NEED (1) Describe the project’s location in the service/market area, the proposed hours of operation of the new service and the reasons for choosing such location: "[Click & type]" (a) Attach a map indicating the location of the proposed project and the location of other facilities within your service area that offer the services proposed or similar or related services. (b) Attach a copy of a site plan, if available. (2) Describe the services that are under consideration for this certificate of need (CON), including recognized categories of the service(s) and service capabilities not available through the technology or equipment the applicant proposes to purchase or use, but which are available through alternate technologies. "[Click & type]" (3) Describe the current health care system in which your proposed project shall be located: "[Click & type]" and include: (a) An outline of the geographic area of the primary and secondary service/market areas. "[Click & type]" (b) A description of the target audience indicated by age and sex cohorts. "[Click & type]" (c) An outline of the utilization rates of services expressed as: (i) Patient days and patient days per thousand residents; "[Click & type]" (ii) Hours; "[Click & type]" (iii) Procedures and procedures per thousand residents; "[Click & type]" (iv) Scans and scans per thousand residents; "[Click & type]" (v) Encounters and encounters per thousand residents; or "[Click & type]" (vi) Other such terms as relates to the proposed project. "[Click & type]" USVI CON Application – Page 7 of 17 DOH Form Revised 02/13/2024 (d) State rates in (c) above individually for each of the following categories: (i) Medicare; "[Click & type]" (ii) Medicaid; "[Click & type]" (iii) Private payor; "[Click & type]" (iv) Commercial insurance; "[Click & type]" (v) Other. "[Click & type]" (4) Describe the road network, travel conditions and, if any, the existence of access problems in the service/market area in which your proposed project shall be located. "[Click & type]" (5) Describe the project’s relationship to the service/market area, island, and the Virgin Islands as a whole or in terms of types and/or quantities of services. "[Click & type]" (6) Describe the health needs of the current population in the proposed service/market areas. "[Click & type]" (7) Describe your proposed plans to provide services to specific populations that are not being served locally or territory-wide at the present time. "[Click & type]" (8) Evaluate alternative proposals you considered in the development of this application which examines the current inventories of beds, services, equipment or trends locally and in the Virgin Islands. "[Click & type]" (9) Evaluate the service capabilities of equipment and technologies to be used in connection with the project. "[Click & type]" (10) Attach an evaluation of alternate technologies that addresses: (a) The capability of such technology to provide diagnostic information or therapeutic treatment similar to the equipment that you propose to acquire; "[Click & type]" USVI CON Application – Page 8 of 17 DOH Form Revised 02/13/2024 (b) The capability of such technology to provide diagnostic information or therapeutic treatment that the equipment you propose to acquire does not have; "[Click & type]" (c) The capability of such technology to be used with respect to a class of patients that the equipment you propose to acquire does not have; "[Click & type]" (d) Whether the technology exists in the market or publicly known to be under development at this time. "[Click & type]" (11) Describe your project's uniqueness in terms of services, service delivery or specific population groups that you have identified in your service/market area, island, or the Virgin Islands as a whole. "[Click & type]" (12) Describe the accessibility of the proposed service to the population in the service area, including accessibility to managed care and Medicaid patients. "[Click & type]" (13) Attach an evaluation of your project’s ability to maintain or improve: (a) Quality of care; "[Click & type]" (b) Access and availability to health services; "[Click & type]" (c) Cost effectiveness of health services provided. "[Click & type]" (14) To the extent data is available, attach a statistical report which shows how the proposed project is projected to affect the proposed service area in terms of: (a) Utilization; "[Click & type]" (b) Patient charges; "[Click & type]" (c) Market share; "[Click & type]" (d) Physician referral patterns; and "[Click & type]" USVI CON Application – Page 9 of 17 DOH Form Revised 02/13/2024 (e) Personnel services. "[Click & type]" (15) Attach any correspondence from other facilities in the service area regarding the impact of the proposed project including the continued ability to: (a) Maintain quality services; (b) Provide essential community services; (c) Provide emergency services; and (d) Provide charity care. PART B - INTEGRATION INTO THE CURRENT HEALTH CARE SYSTEM (1) Describe the proposed project intended service linkages with other health care facilities and programs to maintain continuity and enhancement of patient care. "[Click & type]" (2) Describe the plan, if any, for making the proposed service available on a 24 hours a day, 7 days a week basis, if applicable. "[Click & type]" (3) Describe the anticipated outcome of integrating the proposed project into the existing health care system. "[Click & type]" PART C - ACCESSIBILITY OF THE PROPOSED PROJECT TO THE MEDICALLY UNDERSERVED (1) Identify the medically underserved population which this project will affect, including but not limited to: (a) Indigent and low income persons; "[Click & type]" (b) Persons who are uninsured; "[Click & type]" (c) Persons for whom language is a barrier; "[Click & type]" (d) Persons classified as having a disability under the Americans with Disabilities Act; "[Click & type]" (e) Persons residing in a designated health shortage service area; "[Click & type]" (f) Other (specify). "[Click & type]" USVI CON Application – Page 10 of 17 DOH Form Revised 02/13/2024 (2) Discuss how health care services will be provided to 100% of the identified medically underserved population by identifying the delivery method as: (a) A direct service offering; (b) A service contract with another supplier; or (c) Both (a) and (b). "[Click & type]" (3) Discuss a financial assistance plan that will be offered to persons who are uninsured or who do not have the financial resources to pay for services offered by the proposed project due to financial hardship. "[Click & type]" PART D - QUALITY OF CARE (1) Discuss a proposed quality assurance plan to enhance the delivery of services. "[Click & type]" (2) Discuss an evaluation of the quality of any equipment or technology to be used or purchased in connection with the project, as compared to other available technologies or equipment. "[Click & type]" (3) Discuss how services will be located in an environment that is free of excessive noise, dust, and hazards or other problems which may be detrimental to patients in terms of safety and comfort. "[Click & type]" (4) Provide a signed statement by the owner or chief executive officer of the applicant attesting that: (a) No current officer, manager, director or trustee of the applicant and no facility owned or operated by the applicant, its parent or any officer, manager, director, or trustee of the applicant or affiliate has had its operating license revoked, Medicare or Medicaid certification or participation involuntarily terminated and such license or participation has not been reinstated; nor has the applicant, parent organization, affiliated organization or current officer, manager, director or trustee been found liable of civil or criminal Medicare or Medicaid fraud; (b) Neither the applicant nor any affiliate has been convicted or found liable for a pattern of patient abuse; (c) Agreements between the applicant and any other person relating to the proposed service are not inconsistent with a reasonable interpretation of any federal or local anti-referral or fraud and abuse prohibitions. (5) If you are unable to provide the signed statement described in (4) above, provide: (a) A signed statement setting forth the facts and circumstances which are inconsistent with the content of the statement described in (4) above; (b) Evidence which demonstrates that the inconsistent facts and circumstances shall not affect the integrity of the services provided by this project; (c) A signed statement containing as much of the content of the statement described in (4) above or other standard as is true. USVI CON Application – Page 11 of 17 DOH Form Revised 02/13/2024 PART E - PROJECT AFFORDABILITY/FINANCIAL FEASIBILITY (1) Provide a statement of sources of funds that will be available to support the project, including your own sources in the form of equity and/or borrowings from a lender. (2) Discuss the effect your project will have on operating and capital expenses and income for the period immediately prior to, during and for 3 years after project completion. "[Click & type]" (3) Include a financial study indicating that revenues shall be available in sufficient quantity to support the present operating levels, the added operating costs and, if applicable, the added debt service of your facility. (4) Provide a study of the anticipated impact the proposed project will have on costs and charges on your facility by including: (a) Your proposed charges for the project services for a period of 3 years after project completion; (b) Your anticipated adjustments to charges for your other health care services as a direct result of the project through the end of the third year following project completion. PART F - CONSTRUCTION METHODS Provide an overall analysis of the methods of construction considered in developing your project and include the following information: (1) A description of the type of construction. "[Click & type]" (2) Drawings of floor plans providing: (a) A depiction of your facility prior to and after project completion. (b) The floor layout including the size and number of all rooms including the size of the scale used in the development of the overall plans. (3) A discussion of the structural design as it relates to the possibility of vertical and/or horizontal expansion of the building(s). "[Click & type]" (4) A site plan which indicates: (a) The orientation of the building(s) on the property; (b) The main entry way; (c) The relationship of these locations to the northern point on the compass. (5) An indication of the anticipated useful life of the building(s). "[Click & type]" (6) A description of the end results of your proposed project in terms of construction, renovation and alterations. "[Click & type]" USVI CON Application – Page 12 of 17 DOH Form Revised 02/13/2024 PART G - PROJECT COSTS Provide an outline of the project costs and include the following items: I. FEES (1) Legal fees which include the anticipated local or other fees for licenses, permits or other regulatory requirements associated with your project. "[Click & type]" (2) Consulting fees which include the anticipated fees to be charged by individuals under contractual arrangement for services rendered in relation to this project. "[Click & type]" (3) Financial feasibility fees which include the anticipated fees to be charged by an accountant or financial advisor in the preparation of the financial statements and feasibility study for this project. "[Click & type]" (4) Architect and engineering fees which include the anticipated fees to be charged by an architect and/or engineer in the preparation of drawings and plans for this project. "[Click & type]" 5) Other fees, which include any other fees that are associated with this project but are not included in (1) to (4) above (specify). "[Click & type]" Subtotal, Fees "[Click & type]" II. LAND ACQUISITION AND SITE DEVELOPMENT (1) Real estate acquisition, including the anticipated cost of acquiring land and/or buildings to accommodate this project. "[Click & type]" (2) Site preparation, including the anticipated cost of preparing the building site for construction, alteration or renovation such as, but not limited to, excavation and backfilling. "[Click & type]" (3) Costs for utilities, including the anticipated cost of expanding, replacing or adding new utilities for water, electricity, telephone and sewage. "[Click & type]" (4) Soil survey and evaluation costs, including the anticipated cost of conducting such surveys in order to obtain local or federal building permits. "[Click & type]" Subtotal, Land Acquisition & Site Development "[Click & type]" USVI CON Application – Page 13 of 17 DOH Form Revised 02/13/2024 III. RELOCATION/MOVING COSTS (1) Temporary relocation costs which include the anticipated cost of relocating patients and/or services to a temporary site until the proposed construction, alteration or renovations are completed. "[Click & type]" (2) Moving costs which include the anticipated cost of moving patients and/or equipment from the existing facility to the proposed new facility. "[Click & type]" Subtotal, Relocation/Moving Costs "[Click & type]" IV. CONSTRUCTION COSTS (1) Labor for new construction. "[Click & type]" (2) Labor for renovations and/or alterations. "[Click & type]" (3) Materials for new construction. "[Click & type]" (4) Materials for renovations and/or alterations. "[Click & type]" (5) Fixed equipment for new construction that is affixed to the building. "[Click & type]" (6) Fixed equipment for renovations and/or alterations that is affixed to the building. "[Click & type]" Subtotal, Construction Costs "[Click & type]" V. OTHER CONSTRUCTION COSTS (1) Demolition costs which include the anticipated cost of eliminating existing structures on the property to allow the proposed new construction. "[Click & type]" (2) Contingency costs which include a sum of money budgeted based on the overall construction costs to pay for costs such as change orders that may materialize during the course of the project which were not included in the initial plans. "[Click & type]" (3) Insurance costs during construction which includes the anticipated cost of insurance coverage during the course of the construction project. "[Click & type]" USVI CON Application – Page 14 of 17 DOH Form Revised 02/13/2024 (4) Interest costs during construction which includes the anticipated amount of interest to be paid on the construction loan until permanent financing is obtained. "[Click & type]" Subtotal, Other Construction Costs "[Click & type]" VI. MAJOR MOVABLE EQUIPMENT Major movable equipment including the anticipated cost of all equipment that is not permanently affixed to the building (include an itemized list). "[Click & type]" Subtotal, Major Movable Equipment "[Click & type]" VII. FINANCING COSTS (1) Bond discount which includes the anticipated sale of bonds on the market at a price less than the face amount of such bond. "[Click & type]" (2) Debt service reserve which includes funds held by a trustee under the terms of a bond issue to ensure the payment of principal and interest on long-term debt other than revenue bonds. "[Click & type]" Subtotal, Financing Costs "[Click & type]" VIII. TOTAL PROJECT COST Total Project Cost (Sum of sections I through VII above) "[Click & type]" If you do not consider any of the foregoing costs to be capital expenditures, provide an appropriate citation of generally accepted accounting principles and demonstration of consistent application thereof in your financial accounting practices to support your claim. PART H - ANTICIPATED EFFECTS Describe the effect your proposed project will have on: (1) Insurance providers including Medicare, Medicaid, and insurance companies. "[Click & type]" (2) Alternative delivery systems such as health maintenance organizations, preferred provider organizations and independent practice organizations. "[Click & type]" (3) Other payors for health care services, including employers and individuals. "[Click & type]" USVI CON Application – Page 15 of 17 DOH Form Revised 02/13/2024 (4) The availability and affordability of the services represented by the project to persons who are uninsured or otherwise do not have the financial resources to pay for the service. "[Click & type]" (5) The availability and affordability of service capabilities that are not available using the equipment and technologies that are expected to be used in the proposed project, but which are available in the market or under development as of the date of the application. "[Click & type]" PART I - ACCESS TO AND EFFECT ON TRAINING PROGRAMS Identify the resources which will be available in your facility to provide access to professional training programs, which address: (1) The effect your project will have, if any, on the clinical needs of health professional training programs in your geographical area. "[Click & type]" (2) The extent to which health professional schools will have access to the services for training purposes. "[Click & type]" PART J - PROJECT SUPPORT Indicate the degree of support you received or expect to receive for your proposed project and include: (1) The degree of support expressed by other health care providers in the region and the Virgin Islands. "[Click & type]" (2) Support from the businesses industry and third-party payors in the region and the Virgin Islands indicating the anticipated financial impact, if any, your proposed project will have on insurance premiums. "[Click & type]" (3) Support from any and all other interested persons. "[Click & type]" PART K - RELATIVE STANDARDS Address the relative standards listed below: (1) Explain how the proposal will be the most cost-effective means of providing the service and other related services available through alternate products or technologies. "[Click & type]" (2) Explain how the proposal will provide the highest quality and scope of services. "[Click & type]" (3) Explain how the services to be provided will be the most affordable to the public. "[Click & type]" USVI CON Application – Page 16 of 17 DOH Form Revised 02/13/2024 (4) Explain how the proposal maximizes the availability of services to the medically under serviced population, expressed in terms of: (a) Accommodations made for persons with a recognized disability; "[Click & type]" (b) The assistance provided to persons for whom language is a barrier; "[Click & type]" (c) The financial assistance provided to persons who are uninsured or for whom paying for services would be a financial hardship. "[Click & type]" (5) Explain how the proposal minimizes the potential that other services, including service capabilities that your project will not provide, will be or will become unavailable in the service area, or that the unavailability of such service capabilities will not have a materially detrimental effect on the delivery of health care in the service area. "[Click & type]" (6) Discuss how the implementation of your proposal will maximize the benefits which will accrue to the service area. "[Click & type]" (7) Explain how your proposal will exhibit the greatest degree of service sharing or linkages with other health care providers. "[Click & type]" (8) Explain how your proposal will have the least effect on your facility's and other providers' operating costs. "[Click & type]" USVI CON Application – Page 17 of 17 DOH Form Revised 02/13/2024 SECTION V - APPENDIX Include any supporting information, documents and exhibits in a section of the application designated as the Appendix, with each section appropriately referenced, labeled and all pages numbered.