Preview
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
PICU Decertification
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
Executive Summary
In accordance with Section 710.1(c)(5) of 10 New York Codes, Rules and Regulations (10 NYCRR),
Mount Sinai Beth Israel (MSBI) is submitting this Service Delivery Limited Review Application that
seeks approval for the decertification of all five (5) inpatient Pediatric Intensive Care Unit (PICU) beds at
the Hospital. MSBI is currently certified for five (5) PICU beds, among other certified bed
classifications, for a total of 799 certified inpatient beds. The PICU beds, which the Hospital would like
to close on January 1, 2017, are located on the 6th Floor of the Dazian Building on the MSBI campus.
Upon implementation of this project, all five (5) PICU beds will be decertified, resulting in a total
inpatient bed count of 794 at MSBI. MSBI is located at First Avenue at 16th Street, New York (New
York County), New York 10003.
It should be noted that the Hospital is concurrently submitting a separate Limited Review Application for
the decertification of all 20 inpatient pediatric beds at the Hospital, for the same reasons noted below. It
is being submitted under a separate Application due to the different timeframes for decertification of beds.
This project is part of a larger effort of Mount Sinai to create a more integrated healthcare system, and to
more effectively use system resources. In the first nine (9) months of 2016, MSBI experienced 112
discharges (with 402 patient days) for its five (5) PICU beds, representing an occupancy rate of 29.3%,
which was a decrease from the 41.7% occupancy rate it experienced for its PICU beds in 2012. That is, in
the first nine (9) months of 2016, only about 1.5 PICU beds were being utilized at any given time.
Importantly, in September 2016, the PICU at MSBI had an average daily census of less than one (1)
patient. Through this project, the relatively few PICU patients who would typically be seen at MSBI will
now be seen at Mount Sinai Hospital in Manhattan (through a separate Application to be submitted in the
future, Mount Sinai Hospital will be adding certified PICU beds).
The overall occupancy rate for the 16 PICU beds at MSH in the first nine (9) months of2016 was 77.8%,
so there is sufficient capacity at MSH to be able to serve MSBI's patients once the PICU at MSBI is
closed. Although MSBI understands that some individuals may choose to seek care outside of the Mount
Sinai system, the Hospital believes that this project is in the best interest of patients from a clinical
perspective, given its plans for the transformation of the MSBI campus.
At no point will access to Mount Sinai physicians be interrupted. Additionally, Mount Sinai does not
anticipate any job losses as a result of the closure of the inpatient PICU at MSBI, and it has already begun
meeting and working with its union partners to ensure that any affected union employees are retrained, if
necessary, and offered other union opportunities with equal pay within the Mount Sinai Health System.
The Total Project Cost for this project is $500, which is comprised solely of the Limited Review
Application fee, and is being submitted as part of initial submission of the Application.
c
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Limited Review Application
State of New York Department of Health
Office of Primary Care and Health Systems Management
LRA Cover Sheet
Project to be Proposed/Applicant Information
This application is for those projects subject to a limited review pursuant to 10 NYCRR 710.l(c){5)-(7). Please check the appropriate
box(es) reflective of the project being proposed by your facility (NOTE - Some projects may involve requisite "Construction". If so,
and total project costs are below designated thresholds, then both boxes must be checked and necessary LRA Schedules submitted).
Please read the LRA Instructions to ensure submission of an appropriate a11d complete application:
D Minor Construction- Minor construction project with total project costs of up to $6,000,000 (or up to $15,000,000, if not
relating to clinical space - check "Non-Clinical" box below).
Necessary LRA Schedules: Cover Sheet, 2, 3, 4, 5, and 6.
D Equipment- Project related to the acquisition, relocation, installation or modification of certain medical equipment, with
total project costs of up to $6,000,000. (NOT necessary for "1-for-l" replacement of existing equipment without
construction, pursuant to Chapter 174 of the Laws of2011 amending Article 28 of the Public Health law to eliminate limited
review and CON review for one for one equipment replacement)
Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and 5.
[8J Service Delivery- Project to decertify a facility's beds/services; add services which involve a total project cost under
$6,000,000; or convert beds within approved categories. (If construction associated, also check "Construction" above.)
Necessary LRA Schedules: Cover Sheet, 7, 8, 10, and 12. *Ifproposing to decertifY beds within a nursing home, provide a
description ofthe proposed alternative use ofthe space including a detailed sketch (unless the decertification is being
accomplished by eliminating beds in multiple-bedded rooms).
D Health Information Technology- Project to purchase and implement health information technology or
other information systems, with a total project cost between $6,000,000 and $15,000,000.
Necessary LRA Schedules: Cover Sheet, 2, 3, 9, and 12. Also include Vendor Contract language (Appendix D).
D Cardiac Services- Project by an appropriately certified facility to add electrophysiology (EP) services;
or add, upgrade or replace a cardiac catheterization laboratory or equipment. (Ifconstruction
associated, also check "Construction" above.)
NecessaryLRA Schedules: Cover Sheet, 7, 8, 10, and 12.
D Relocation of Extension Clinic - Project to relocate an extension clinic within the same service area.
Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and 5. Also Include a Closure Plan for vacating extension clinic.
D Part-Time Clinic- Project to operate, change services offered, change hours of operation or relocate a part-time clinic
site- for applicants already certified for "part-time clinic". (Ifconstruction associated, also check "Construction"
above.)
Necessary LRA Schedules: Cover Sheet, 8, 10, 11, and 12.
OPERATING CERTIFICATE NO. CERTIFIED OPERATOR TYPE OF FACILITY
7002002H Mount Sinai Beth Israel Hospital
OPERATOR ADDRESS- STREET & NUMBER PFI NAME AND TITLE OF CONTACT PERSON
First A venue at 16lh Street 1439 Frank M. Cicero, Cicero Consulting Associates
CITY
New York
I
COUNTY
New York
ZIP
10003
STREET AND NUMBER
701 Westchester Avenue, Suite 210W
PROJECT SITE ADDRESS- STREET & NUMBER
First A venue at 16tl1 Street
PFI
1439
CITY
White Plains
INY
STATE IZIP
10604
CITY
New York
I
COUNTY
New York
ZIP
10003
TELEPHONE NUMBER
(914) 682-8657
IFAXNUMBER
(914) 682-8895
TOTAL PROJECT COST: $ 500 (Application Fee only) CONTACT E-MAIL: conadmin@ciceroassociates.com
(Rev S/2014)
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Limited Review A plication Schedule LRA 7
State of New York Department of Health/Office of Health Systems Management
Proposed Operating Budget
Budget Current Year** First Year** Third Year**
(Projected) (Projected)
Revenues
Service Revenue $5,326,580 ($5,326,580) ($5,326,580)
Grants Funds
Foundation
Other
Fees
Other Income
(1) Total Revenues $ 5,326,580 ($5,326,580) ($5,326,580)
Expenses
Salaries and Wage Expense $2,498,048 ($2,498,048) ($2,498,048)
Employee Benefits $1,228,145 ($1,228,145) ($1,228,145)
Professional Fees
Medical & Surgical Supplies
Non-Medical Equipment
Purchased Services
Other Direct Expense $578,737 ($578,737) ($578,737)
Utilities Expense
Interest Expense
Rent Expense
Depreciation Expense
Other Expenses
(2) Total Expense $ 4,304,930 $ ( 4,304,930) $ (4,304,930)
Net Total - (1-2) $ 1,021,650 $ (1,021,650) $ (1,021,650)
**The Current Year represents year 2015 statistics for the PICU beds at MSBI. The incremental Year 1 and
Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project.
(Rev. 7/2015) 1
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Limited Review Aeplication
State of New York Department of Healtb/Office of Healtb Systems Management
Ischedule LRA 7
• Various inpatient services may be reimbursed as discharges or days. Applicant should indicate which method checkbox.
applies to this table by choosing the appropriate checkbox
Patient Days 0 Patient Discharges
Inpatient Services Source of Total Current Year** First Year Incremental** Third Year Incremental**
Revenue Patient Net Revenue* Patient Days Net Revenue* Patient Days Net Revenue*
Days or or or
% Dollars($) % Dollars-($) % Dollars-($)
discharges* discharges• discharges*
Commercial Fee for
Service 79 43.6% $3,782,797 (79) 43.6% ($3,782,797 (79 43.6% ($3,782 797'
Managed
care 3 1.7% $49 981 {3) 1.7% ($49,981) (3' 1.7% ($49,981
Medicare Fee for
Service I 0.6% $6,198 (I' 0.6% ($6,198) en 0.6% ($6,198
Managed
Care $0 $0
Medicaid Fee for
Service 13 7.2% $189,495 (13 7.2% ($189,495 (13 7.2% ($189,495)
Managed
Care 84 46.4% $1,298,109 (84\ 46.4% ($1,298,109 (84 46.4% ($1,298, 109'
Private Pay I 0.6% $0 (1) 0.6% $0 (1) 0.6% $0
OASAS
OMH
Charity Care
Bad Debt
All Other
Total 181 100.0% $5,326,580 (181) 100.0% ($5,326,580) (181) 100.0% ($5,326,580)
•• The Current Year represents year 2015 statistics for the PICU beds at MSBI. The incremental Year 1 and Year 3 operating budget demonstrates
that the beds will be decertified by MSBI through this project.
(Rev. 7/2015) 2
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Oupatient Services Total Current Year First Year Incremental Third Year Incremental
Source of Revenue Net Revenue Net Revenue Net Revenue
Visits Visits Visits
% Dollars($) % Dollars($) % Dollars($)
Commercial Fee for
Service
Managed
Care
Medicare Fee for
Service N/A N/A N/A
Managed
Medicaid
Care
Fee for
--- -- --
Service Inpatient Jnpatient Inpatient
Managed
Care Project Only Project Only Proiect Only
Private Pay
OASAS
OMH
Charity Care
Bad Debt
All Other
Total
Total of Inpatient
and Outpatient
Services $5,326 580 ($5,326,580 ($5,326,580'
Title of Attachment Filename of Attachment
' I. ln an attacnment,
Revenues by payer are
provide the basis and
based upon the
supporting calculations N/A
experience of the
for all revenues by
Hospital.
IJ!ayor.
2. In an attachment, Private Pay/Charity Care
provide the basis for based on the experience N/A
charity care. of the Hospital.
(Rev. 7/2015) 3
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
Limited Review Application
State of New York Department of Health/Office of Health Systems Management
Schedule LRA 8 -
Staffing
Number of FTEs to the Nearest Tenth
Staffing Categories Current Year* First Year of Third Year of
**** implementation implementation
**** ****
Health Providers**:
Physician 8.5 (8.5) (8.5)
Registered Nurse 6.7 (6.7) (6.7)
Licensed Clinical Social Worker 0.5 (0.5) (0.5)
Respiratory Therapist 0.1 (0.1) (0.1)
Support Staff***:
Orderlies 3.7 (3.7) (3.7)
Clerical and Other Administrative 2.4 (2.4) (2.4)
Child Life Specialist 0.5 (0.5) (0.5)
Housekeeping 1.0 (l.O) (1.0)
Total Number ofEmployees 23.4 (23.4) (23.4)
..
* Last complete year pnor to submtttmg apphcat10n
** "Health Providers" includes all providers serving patients at the site. A Health Provider is any staff who can
provide a billable service- physician, dentist, dental hygienist, podiatrist, physician assistant, physical therapist, etc.
*** All other staff.
****The Current Year represents year 2015 staffing for the PICU beds at MSBI. The incremental Year 1 and Year 3
operating budget demonstrates that the beds will be decertified by MSBI through this project.
Describe how the number and mix of staff were determined:
The number and mix of staff were based upon the fact that all five (5) certified inpatient PICU beds will be decertified
through this project. Nevertheless, Mount Sinai does not anticipate any job losses as a result of the closure of the
inpatient PICU at MSBI, and it has already begun meeting and working with its union partners to ensure that any
affected union employees are retrained, if necessary, and offered other union opportunities with equal pay within the
Mount Sinai Health System.
PLEASE COMPLETE THE FOLLOWING:
1. Are staff paid and on payroll? rgj Yes 0 No
2. Provide copies of contracts for any independent contractor. N/A
3. Please attach the Medical Doctors C.V. Please refer to the Schedule LRA 8 Attachment
4. Is this facility affiliated with any other facilities? rgj Yes 0 No Please refer to the Schedule LRA
(If yes, please describe affiliation and/or agreement.) 8 Attachment
(Rev. 71712010)
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
MOUNT SINAI BETH ISRAEL
SCHEDULELRA8ATTACHMENT
CURRICULUM VITAE- MEDICAL DIRECTOR
AND
STATEMENT RE: ARTICLE 28 NETWORK
FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024
NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
CURRICULUM VITAE
EDWARD E. CONWAY, JR., M.D., M.S.
1. Date of Birth: August 8, 1956
2. Education:
A. University
1974-1978 Manhattan College, B.S., Biology
1978-1979 Fordham University, M.S., Cell Biology
1980-1984 State University of New York, Downstate Medical School, M.D.
B. Post Graduate Trainin2:
July 1984-June 1985 Pediatric Internship, Albert Einstein College of Medicine
Hospitals, Bronx, New York
July 1985-June 1987 Pediatric Residency, Albert Einstein College of Medicine
Hospitals, Bronx, New York (PGY 2 and 3)
July 1987-June 1988 Chief Residency in Pediatrics, Albert Einstein College of
Medicine Hospitals, Bronx, New York (PGY 4)
July 1988-June 1990 Fellow in Pediatric Critical Care Medicine, Albert Einstein
College of Medicine Hospitals, Bronx, New York
2000 Leadership Development for Physicians in Academic Health
Centers, Harvard School of Public Health
2002 Finance and Accounting Program Sponsored by Johnson
Graduate School ofManagement of Cornell University.
3. Professional Appointments:
A. University
Aug 1979-Aug 1980 Research Assistant, Department of Neurosurgery
Albert Einstein College of Medicine, Bronx, New York
July 1990-June 1995 Assistant Professor of Pediatrics and Critical Care
Medicine, Albert Einstein College of Medicine,
Bronx, New York
July 1991-June 1995 Assistant Professor of Anesthesiology,
Albert Einstein College of Medicine, Bronx, New York
July 1995-June 2001 Associate Professor of Pediatrics
Albert Einstein College of Medicine, Bronx, New York
July 2001-Present Professor of Clinical Pediatrics
Albert Einstein College of Medicine, Bronx, New York
1.
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B. Hospital
July 1988-June 1996 Attending Physician, Emergency Department,
Bronx Municipal Hospital Center, Bronx, New York
July 1990-June 1996 Attending Pediatrician, Bronx Municipal Hospital Center,
Bronx, New York
July 1990-June 1996 Attending Pediatrician, North Central Hospital, Bronx, New
York
July 1990-June 1996 Attending Pediatrician
Montefiore Medical Center, Bronx, New York
July 1990-June 1996 Director, Pediatric Critical Care Fellowship Program
Albert Einstein College ofMedicine, Bronx, New York
July 1993-June 1996 Associate Director, Pediatric Critical Care Unit
Children's Medical Center at Montefiore, Bronx, New York
July 1994-June 1996 Consultant in Pediatric Critical Care Medicine
Flushing Meadow Medical Center, New York
July 1996-Present Attending Pediatrician, Beth Israel Medical Center,
New York, NY
July 1996-0ct 2000 Associate Chairman, Department of Pediatrics,
Beth Israel Medical Center, New York, NY
Nov 1997-June 1998 Acting Medical Director, Institute of Neurology and Neurosurgery,
Beth Israel Medical Center, New York, NY
July 1996-Present Chief, Division of Pediatric Critical Care,
Beth Israel Medical Center, New York, NY
July 1999-2008 Senior Attending Pediatrician
St. Luke's/Roosevelt Hospital Center
Feb 2000-Nov 2000 Associate Medical Director, Beth Israel Medical
Center/Singer Division
Oct 2000-Dec -2003 Acting Chairman, Department of Pediatrics,
Beth Israel Medical Center
Jan 2004 -Present Chairman, Department of Pediatrics and
Pediatrician in Chief of the Milton and Bernice Stern
Department of Pediatrics/Beth Israel Medical Center
March 2012-2013 Interim Chairman, Department of Pediatrics and
Pediatrician in Chief St. Luke's and Roosevelt Hospital
May 2013- Interim Chairman, Department of Pediatrics and
Pediatrics in Chief St. Luke's and Roosevelt Hospitals
4. Medical License:
1985 162704 New York State
2003 25MA07694700 New Jersey
2.
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5. Certification:
1985 Diplomate, National Board of Medical Examiners (289948)
1988 Diplomate, American Board of Pediatrics (ABP: 38147)
1990-1997 Diplomate, Sub-Board Critical Care Medicine,
Amet·ican Board ofPediatrics (#000202)
1997-2004 Recertification in Pediatric Critical Care Medicine (ABP: 000202)
2001-2007 Recertification in General Pediatrics (ABP: 038147)
2002-2012 Recertification in Pediatric Critical Care Medicine (ABP: 000202)
2007-2014 Recertification in General Pediatrics (ABP: 038147)
2012-2022 Recertification in Pediatric Critical Care Medicine (ABP: 000202)
Professional Society Memberships:
1988- Member, Society of Critical Care Medicine
1988- Fellow, American Academy of Pediatrics
1988- Pediatric Alnmni Association, SUNY,
Health Science Center, Brooklyn, New York
1989- Member, New York Society of Pediatric Critical Care
Medicine
1989- Member, American Academy of Pediatrics,
Section on Pediatric Critical Care Medicine
1990- Montefiore Medical Center Alumni Association
1990- Albert Einstein College of Medicine Pediatric Alumni
Association
1992- Member, American Academy of Pediatrics,
Section on Injury and Poison Prevention
1992 Member, American Academy of Pediatrics,
Section on Emergency Medicine
1995- Member, American Academy of Pediatrics,
Section on Child Abuse and Prevention
1999- Member, American College of Physician Executives
2002-2007 Treasurer, New York Society of Pediatric Critical Care Medicine
6. Other Professional Activities:
A. Intramural Activities and Committees
1984-1989 Pediatric Housestaff Education Committee
1988- Instructor, Pediatric Advanced Life Support
1989-1995 Lecturer, Advanced Cardiac Life Support
1990-1994 Hospital Utilization Review Committee, Montefiore Medical Center
1990-1992 Member, Faculty Student Senate, Albert Einstein College of Medicine
1990-1992 Member, Governance Council, Pediatric Private Practice Plan, Department
of Pediatrics, Albert Einstein College of Medicine
3.
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1991-1992 Secretary, Governance Council, Pediatric Private Practice Plan,
Department of Pediatrics, Albert Einstein College of Medicine
1992-1996 Member, Pediatric Education Policy and Planning Committee
Albert Einstein College of Medicine
1992-1996 Member, Montefiore Medical Center Cardiac Arrest Committee,
Bronx, New York
1992-1993 Member, Residency Curriculum Subcommittee of the Division of Pediatric
Education/Albert Einstein College of Medicine
1992-1993 Member, Chief Residency Subcommittee of the Division of Pediatric
Education/Albert Einstein College of Medicine
1993-1996 Member, Pediatric Research Advisory Committee,
Albert Einstein College of Medicine
1994-1995 Co-Director, Introduction to Research and Statistics Course for the
Department of Pediatrics Fellowship Training Programs/Albert Einstein
College ofMedicine
1994-1996 Member, Search Committee for the Director of the Division of
Neonatology/Albert Einstein College of Medicine
1995-1996 Member, Governance Council, Pediatric Private Practice Plan,
Department of Pediatrics/Albert Einstein College of Medicine
1995-1996 Director, Introduction to Research and Statistics Course for the Department
of Pediatrics Fellowship Training Programs/Albert Einstein College of
Medicine
1995-2001 Instructor, Problem Based Learning for Medical Students,
Albert Einstein College of Medicine
1996 Chairman, Ad Hoc Committee on Promotions,
Albert Einstein College of Medicine
1996M2004 Member, Ethics Committee, Beth Israel Medical Center/North Division
1996-2000 Member, Committee on Pharmacy and Therapeutics,
Beth Israel Medical Center/North Division
1996-2004 Member, Executive Committee at Beth Israel Medical Center/North Division
1996M2004 Co-Chairman, Pediatric Continuous Quality Improvement Committee at
Beth Israel Medical Center/North Division
1997-2004 Member, Infection Control Committee
at Beth Israel Medical Center/North Division
1998-2000 Medical Student Preceptor for Third Year Pediatric Clerkship
Albert Einstein College of Medicine
1998 Course Director, Pediatric Neurologic Emergencies,
Roosevelt/St. Luke's Medical Center
2000-2008 Member, LICHJBI Pediatric Resident Committee
2000-2008 Member, LICHJBI Residency Review and Recruitment Committee
2001-Present Committee on Professors, Department of Pediatrics, AECOM
2002-2004 Member, Committee on Professorial Promotions, AECOM
2004-Present Member, Pediatric Quality Improvement Committee,
Beth Israel Medical Center
2008-Present Member, Pediatric Medication Error Committee
Beth Israel Medical Center
4.
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MOUNT SINAI BETH ISRAEL
ARTICLE 28 NETWORK DESCRIPTION
Mount Sinai Hospitals Group, Inc. (MSHG), a not-for-profit corporation, is the active parent and
co-operator of Mount Sinai Hospital (including its division, Mount Sinai Hospital of Queens),
Mount Sinai Beth Israel, Mount Sinai Brooklyn, Mount Sinai St. Luke's, Mount Sinai Roosevelt
and the New York Eye and Ear Infirmary of Mount Sinai.
Mount Sinai Hospital (MSH) is located at One Gustave L. Levy Place, New York (New York
County), New York 10029. MSH also has a division, Mount Sinai Hospital of Queens, which is
located at 25-10 30th Avenue, Long Island City (Queens County), New York 11102. Mount
Sinai Beth Israel is located at First Avenue at 16th Street, New York (New York County), New
York 10003. Mount Sinai Brooklyn is located at 3201 Kings Highway, Brooklyn (Kings
County), New York 11234. Mount Sinai St. Luke's is located at 1111 Amsterdam Avenue, New
York (New York County), New York 10025. Mount Sinai Roosevelt is located at 1000 Tenth
Avenue, New York (New York County), New York 10019. New York Eye and Ear Infirmary of
Mount Sinai is located at 310 East 14tli Street, New York (New York County), New York 10003.
The following table provides information on operating certificate numbers and PFI numbers for
the above-referenced facilities:
Operating
PFI#
Facility Name Certificate #
Mount Sinai Hospital 7002024H 1456
Mount Sinai Hospital of Queens 7002024H 1639
Mowtt Sinai Beth Israel 7002002H 1439
Mount Sinai Brooklyn 7002002H 1324
Mount Sinai St. Luke's 7002032H 1469
Mount Sinai Roosevelt 7002032H 1466
New York Eye and Ear Infirmary of Mount Sinai 7002026H 1460
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NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
Limited Review Application. Schedule·LRA 10 _
State of New York Department of Health/Office of Health Systems Management
Impact of Limited Review Application on Operating Certificate
(services specific to the site)
Instructions:
"Current" Column: Mark "x" in the box only if the service currently appears on the operating certificate (OpCert) not
including requested changes
"Add" Column: Mark "x" in the box this CON application seeks to add.
"Remove" Column: Mark "x" in the box this CON application seeks to decertifY.
"Pro osed" Column: Mark "x" in the box corres ondin to all the services that will ultimately a
ratel!orv/Authorized Service Code Current Add Remove Proposed
Chemical Dependence - Rehabilitation --- 30 30
Chemical Dependence - Detoxification --- 31 31
Coronary Care --- 8 8
Intensive Care --- 36 36
Maternity --- 42 42
Medical/Surgical --- 504 504
Neonatal Continuing Care --- 14 14
Neonatal Intermediate Care --- 17 17
Pediatric --- 20 20
Pediatric ICU --- 5 -5 0
Psychiatric --- 92 92
Note: MSBI is concurrently submittim! a separate Limited Review Application for the decertification of all 20
inpatient pediatric beds at the HosDital for the same reasons as noted in this Aonlication. It is beinl! submitted under
a senarate Application due to the different timeframes for decertification of beds.
TOTAL 799 -5 794
Does the applicant have any previously submitted Certificate of Need (CON) applications that have not been
completed inv~lving addition or decertification of beds?
[giNo
0 Yes (Enter CON numbers to the right)
(Rev. 717/2010}
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NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024
Limited Review Application Schedule LRA 12 ~
State of New York Department of Health/Office of Health Systems Management
Assurances
The undersigned, as a duly authorized representative ofthe applicant, hereby gives the following assurances:
a) The applicant has or will have a fee simple or such other estate or interest in the site, including necessary easements and
rights-of-way, sufficient to assut·e use and possession for the purpose ofthe construction and operation of the facility.
b) The applicant will obtain the approval of the Commissioner of Health of all required submissions, which shall conform to the
standards of construction and equipment in Subchapter C ofTitle 10 (Health) of the Official Compilation of Codes, Rules
and Regulations ofthc State of New York (Title 10).
c) The applicant will submit to the Commissioner of Health final wotking drawings and specifications, which shall conform to
the standards of construction and equipment ofSubchaptel' C of Title 10, prior to contracting for construction, unless
otherwise provided for in Title I 0.
d) The applicant will cause the project to be completed in accordance with the application and approved plans and
specifications.
e) The applicant will provide and maintain competent and adequate architectural and/or engineering inspection at the
construction site to insure that the completed work conforms to the approved plans and specifications.
t) If the project is an addition to a facility already in existence, upon completion of construction all patients shall be removed
from areas of the facility that are not in compliance with pertinent provisions of Title l 0, unless a waiver is granted by the
Commissioner of Health, under Title I0.
g) The facility will be operated and maintained in accordance with the standards prescribed by law.
h) The applicant will comply with the provisions ofthe Public Health Law and the applicable pt·ovisions of Title 10 with respect
to the operation of all established, existing medical facilities in which the applicant has a controlling interest.
i} The applicant understands and recognizes that arty approval of this application is not to be construed as an approval of, nor
does it provide assurance of, reimbursement for at1y costs identified in the application. Reimbursement for all cost shall be in
acco1;dance with and subject to the provisions of Part 86 of Title 10.
!1- q-;c.-
Date Signature
I
Kenneth L. Davis, M.D.
Name (Please Type)
President and CEO, Mount Sinai Hospitals G1·oup
Title (Please Type)
(Rev. 71712010)
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FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 PICU Decertification FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Executive Summary In accordance with Section 710.1(c)(5) of 10 New York Codes, Rules and Regulations (10 NYCRR), Mount Sinai Beth Israel (MSBI) is submitting this Service Delivery Limited Review Application that seeks approval for the decertification of all five (5) inpatient Pediatric Intensive Care Unit (PICU) beds at the Hospital. MSBI is currently certified for five (5) PICU beds, among other certified bed classifications, for a total of 799 certified inpatient beds. The PICU beds, which the Hospital would like to close on January 1, 2017, are located on the 6th Floor of the Dazian Building on the MSBI campus. Upon implementation of this project, all five (5) PICU beds will be decertified, resulting in a total inpatient bed count of 794 at MSBI. MSBI is located at First Avenue at 16th Street, New York (New York County), New York 10003. It should be noted that the Hospital is concurrently submitting a separate Limited Review Application for the decertification of all 20 inpatient pediatric beds at the Hospital, for the same reasons noted below. It is being submitted under a separate Application due to the different timeframes for decertification of beds. This project is part of a larger effort of Mount Sinai to create a more integrated healthcare system, and to more effectively use system resources. In the first nine (9) months of 2016, MSBI experienced 112 discharges (with 402 patient days) for its five (5) PICU beds, representing an occupancy rate of 29.3%, which was a decrease from the 41.7% occupancy rate it experienced for its PICU beds in 2012. That is, in the first nine (9) months of 2016, only about 1.5 PICU beds were being utilized at any given time. Importantly, in September 2016, the PICU at MSBI had an average daily census of less than one (1) patient. Through this project, the relatively few PICU patients who would typically be seen at MSBI will now be seen at Mount Sinai Hospital in Manhattan (through a separate Application to be submitted in the future, Mount Sinai Hospital will be adding certified PICU beds). The overall occupancy rate for the 16 PICU beds at MSH in the first nine (9) months of2016 was 77.8%, so there is sufficient capacity at MSH to be able to serve MSBI's patients once the PICU at MSBI is closed. Although MSBI understands that some individuals may choose to seek care outside of the Mount Sinai system, the Hospital believes that this project is in the best interest of patients from a clinical perspective, given its plans for the transformation of the MSBI campus. At no point will access to Mount Sinai physicians be interrupted. Additionally, Mount Sinai does not anticipate any job losses as a result of the closure of the inpatient PICU at MSBI, and it has already begun meeting and working with its union partners to ensure that any affected union employees are retrained, if necessary, and offered other union opportunities with equal pay within the Mount Sinai Health System. The Total Project Cost for this project is $500, which is comprised solely of the Limited Review Application fee, and is being submitted as part of initial submission of the Application. c FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Limited Review Application State of New York Department of Health Office of Primary Care and Health Systems Management LRA Cover Sheet Project to be Proposed/Applicant Information This application is for those projects subject to a limited review pursuant to 10 NYCRR 710.l(c){5)-(7). Please check the appropriate box(es) reflective of the project being proposed by your facility (NOTE - Some projects may involve requisite "Construction". If so, and total project costs are below designated thresholds, then both boxes must be checked and necessary LRA Schedules submitted). Please read the LRA Instructions to ensure submission of an appropriate a11d complete application: D Minor Construction- Minor construction project with total project costs of up to $6,000,000 (or up to $15,000,000, if not relating to clinical space - check "Non-Clinical" box below). Necessary LRA Schedules: Cover Sheet, 2, 3, 4, 5, and 6. D Equipment- Project related to the acquisition, relocation, installation or modification of certain medical equipment, with total project costs of up to $6,000,000. (NOT necessary for "1-for-l" replacement of existing equipment without construction, pursuant to Chapter 174 of the Laws of2011 amending Article 28 of the Public Health law to eliminate limited review and CON review for one for one equipment replacement) Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and 5. [8J Service Delivery- Project to decertify a facility's beds/services; add services which involve a total project cost under $6,000,000; or convert beds within approved categories. (If construction associated, also check "Construction" above.) Necessary LRA Schedules: Cover Sheet, 7, 8, 10, and 12. *Ifproposing to decertifY beds within a nursing home, provide a description ofthe proposed alternative use ofthe space including a detailed sketch (unless the decertification is being accomplished by eliminating beds in multiple-bedded rooms). D Health Information Technology- Project to purchase and implement health information technology or other information systems, with a total project cost between $6,000,000 and $15,000,000. Necessary LRA Schedules: Cover Sheet, 2, 3, 9, and 12. Also include Vendor Contract language (Appendix D). D Cardiac Services- Project by an appropriately certified facility to add electrophysiology (EP) services; or add, upgrade or replace a cardiac catheterization laboratory or equipment. (Ifconstruction associated, also check "Construction" above.) NecessaryLRA Schedules: Cover Sheet, 7, 8, 10, and 12. D Relocation of Extension Clinic - Project to relocate an extension clinic within the same service area. Necessary LRA Schedules: Cover Sheet, 2, 3, 4, and 5. Also Include a Closure Plan for vacating extension clinic. D Part-Time Clinic- Project to operate, change services offered, change hours of operation or relocate a part-time clinic site- for applicants already certified for "part-time clinic". (Ifconstruction associated, also check "Construction" above.) Necessary LRA Schedules: Cover Sheet, 8, 10, 11, and 12. OPERATING CERTIFICATE NO. CERTIFIED OPERATOR TYPE OF FACILITY 7002002H Mount Sinai Beth Israel Hospital OPERATOR ADDRESS- STREET & NUMBER PFI NAME AND TITLE OF CONTACT PERSON First A venue at 16lh Street 1439 Frank M. Cicero, Cicero Consulting Associates CITY New York I COUNTY New York ZIP 10003 STREET AND NUMBER 701 Westchester Avenue, Suite 210W PROJECT SITE ADDRESS- STREET & NUMBER First A venue at 16tl1 Street PFI 1439 CITY White Plains INY STATE IZIP 10604 CITY New York I COUNTY New York ZIP 10003 TELEPHONE NUMBER (914) 682-8657 IFAXNUMBER (914) 682-8895 TOTAL PROJECT COST: $ 500 (Application Fee only) CONTACT E-MAIL: conadmin@ciceroassociates.com (Rev S/2014) FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Limited Review A plication Schedule LRA 7 State of New York Department of Health/Office of Health Systems Management Proposed Operating Budget Budget Current Year** First Year** Third Year** (Projected) (Projected) Revenues Service Revenue $5,326,580 ($5,326,580) ($5,326,580) Grants Funds Foundation Other Fees Other Income (1) Total Revenues $ 5,326,580 ($5,326,580) ($5,326,580) Expenses Salaries and Wage Expense $2,498,048 ($2,498,048) ($2,498,048) Employee Benefits $1,228,145 ($1,228,145) ($1,228,145) Professional Fees Medical & Surgical Supplies Non-Medical Equipment Purchased Services Other Direct Expense $578,737 ($578,737) ($578,737) Utilities Expense Interest Expense Rent Expense Depreciation Expense Other Expenses (2) Total Expense $ 4,304,930 $ ( 4,304,930) $ (4,304,930) Net Total - (1-2) $ 1,021,650 $ (1,021,650) $ (1,021,650) **The Current Year represents year 2015 statistics for the PICU beds at MSBI. The incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project. (Rev. 7/2015) 1 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Limited Review Aeplication State of New York Department of Healtb/Office of Healtb Systems Management Ischedule LRA 7 • Various inpatient services may be reimbursed as discharges or days. Applicant should indicate which method checkbox. applies to this table by choosing the appropriate checkbox Patient Days 0 Patient Discharges Inpatient Services Source of Total Current Year** First Year Incremental** Third Year Incremental** Revenue Patient Net Revenue* Patient Days Net Revenue* Patient Days Net Revenue* Days or or or % Dollars($) % Dollars-($) % Dollars-($) discharges* discharges• discharges* Commercial Fee for Service 79 43.6% $3,782,797 (79) 43.6% ($3,782,797 (79 43.6% ($3,782 797' Managed care 3 1.7% $49 981 {3) 1.7% ($49,981) (3' 1.7% ($49,981 Medicare Fee for Service I 0.6% $6,198 (I' 0.6% ($6,198) en 0.6% ($6,198 Managed Care $0 $0 Medicaid Fee for Service 13 7.2% $189,495 (13 7.2% ($189,495 (13 7.2% ($189,495) Managed Care 84 46.4% $1,298,109 (84\ 46.4% ($1,298,109 (84 46.4% ($1,298, 109' Private Pay I 0.6% $0 (1) 0.6% $0 (1) 0.6% $0 OASAS OMH Charity Care Bad Debt All Other Total 181 100.0% $5,326,580 (181) 100.0% ($5,326,580) (181) 100.0% ($5,326,580) •• The Current Year represents year 2015 statistics for the PICU beds at MSBI. The incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project. (Rev. 7/2015) 2 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Oupatient Services Total Current Year First Year Incremental Third Year Incremental Source of Revenue Net Revenue Net Revenue Net Revenue Visits Visits Visits % Dollars($) % Dollars($) % Dollars($) Commercial Fee for Service Managed Care Medicare Fee for Service N/A N/A N/A Managed Medicaid Care Fee for --- -- -- Service Inpatient Jnpatient Inpatient Managed Care Project Only Project Only Proiect Only Private Pay OASAS OMH Charity Care Bad Debt All Other Total Total of Inpatient and Outpatient Services $5,326 580 ($5,326,580 ($5,326,580' Title of Attachment Filename of Attachment ' I. ln an attacnment, Revenues by payer are provide the basis and based upon the supporting calculations N/A experience of the for all revenues by Hospital. IJ!ayor. 2. In an attachment, Private Pay/Charity Care provide the basis for based on the experience N/A charity care. of the Hospital. (Rev. 7/2015) 3 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Limited Review Application State of New York Department of Health/Office of Health Systems Management Schedule LRA 8 - Staffing Number of FTEs to the Nearest Tenth Staffing Categories Current Year* First Year of Third Year of **** implementation implementation **** **** Health Providers**: Physician 8.5 (8.5) (8.5) Registered Nurse 6.7 (6.7) (6.7) Licensed Clinical Social Worker 0.5 (0.5) (0.5) Respiratory Therapist 0.1 (0.1) (0.1) Support Staff***: Orderlies 3.7 (3.7) (3.7) Clerical and Other Administrative 2.4 (2.4) (2.4) Child Life Specialist 0.5 (0.5) (0.5) Housekeeping 1.0 (l.O) (1.0) Total Number ofEmployees 23.4 (23.4) (23.4) .. * Last complete year pnor to submtttmg apphcat10n ** "Health Providers" includes all providers serving patients at the site. A Health Provider is any staff who can provide a billable service- physician, dentist, dental hygienist, podiatrist, physician assistant, physical therapist, etc. *** All other staff. ****The Current Year represents year 2015 staffing for the PICU beds at MSBI. The incremental Year 1 and Year 3 operating budget demonstrates that the beds will be decertified by MSBI through this project. Describe how the number and mix of staff were determined: The number and mix of staff were based upon the fact that all five (5) certified inpatient PICU beds will be decertified through this project. Nevertheless, Mount Sinai does not anticipate any job losses as a result of the closure of the inpatient PICU at MSBI, and it has already begun meeting and working with its union partners to ensure that any affected union employees are retrained, if necessary, and offered other union opportunities with equal pay within the Mount Sinai Health System. PLEASE COMPLETE THE FOLLOWING: 1. Are staff paid and on payroll? rgj Yes 0 No 2. Provide copies of contracts for any independent contractor. N/A 3. Please attach the Medical Doctors C.V. Please refer to the Schedule LRA 8 Attachment 4. Is this facility affiliated with any other facilities? rgj Yes 0 No Please refer to the Schedule LRA (If yes, please describe affiliation and/or agreement.) 8 Attachment (Rev. 71712010) FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 MOUNT SINAI BETH ISRAEL SCHEDULELRA8ATTACHMENT CURRICULUM VITAE- MEDICAL DIRECTOR AND STATEMENT RE: ARTICLE 28 NETWORK FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 CURRICULUM VITAE EDWARD E. CONWAY, JR., M.D., M.S. 1. Date of Birth: August 8, 1956 2. Education: A. University 1974-1978 Manhattan College, B.S., Biology 1978-1979 Fordham University, M.S., Cell Biology 1980-1984 State University of New York, Downstate Medical School, M.D. B. Post Graduate Trainin2: July 1984-June 1985 Pediatric Internship, Albert Einstein College of Medicine Hospitals, Bronx, New York July 1985-June 1987 Pediatric Residency, Albert Einstein College of Medicine Hospitals, Bronx, New York (PGY 2 and 3) July 1987-June 1988 Chief Residency in Pediatrics, Albert Einstein College of Medicine Hospitals, Bronx, New York (PGY 4) July 1988-June 1990 Fellow in Pediatric Critical Care Medicine, Albert Einstein College of Medicine Hospitals, Bronx, New York 2000 Leadership Development for Physicians in Academic Health Centers, Harvard School of Public Health 2002 Finance and Accounting Program Sponsored by Johnson Graduate School ofManagement of Cornell University. 3. Professional Appointments: A. University Aug 1979-Aug 1980 Research Assistant, Department of Neurosurgery Albert Einstein College of Medicine, Bronx, New York July 1990-June 1995 Assistant Professor of Pediatrics and Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York July 1991-June 1995 Assistant Professor of Anesthesiology, Albert Einstein College of Medicine, Bronx, New York July 1995-June 2001 Associate Professor of Pediatrics Albert Einstein College of Medicine, Bronx, New York July 2001-Present Professor of Clinical Pediatrics Albert Einstein College of Medicine, Bronx, New York 1. FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 B. Hospital July 1988-June 1996 Attending Physician, Emergency Department, Bronx Municipal Hospital Center, Bronx, New York July 1990-June 1996 Attending Pediatrician, Bronx Municipal Hospital Center, Bronx, New York July 1990-June 1996 Attending Pediatrician, North Central Hospital, Bronx, New York July 1990-June 1996 Attending Pediatrician Montefiore Medical Center, Bronx, New York July 1990-June 1996 Director, Pediatric Critical Care Fellowship Program Albert Einstein College ofMedicine, Bronx, New York July 1993-June 1996 Associate Director, Pediatric Critical Care Unit Children's Medical Center at Montefiore, Bronx, New York July 1994-June 1996 Consultant in Pediatric Critical Care Medicine Flushing Meadow Medical Center, New York July 1996-Present Attending Pediatrician, Beth Israel Medical Center, New York, NY July 1996-0ct 2000 Associate Chairman, Department of Pediatrics, Beth Israel Medical Center, New York, NY Nov 1997-June 1998 Acting Medical Director, Institute of Neurology and Neurosurgery, Beth Israel Medical Center, New York, NY July 1996-Present Chief, Division of Pediatric Critical Care, Beth Israel Medical Center, New York, NY July 1999-2008 Senior Attending Pediatrician St. Luke's/Roosevelt Hospital Center Feb 2000-Nov 2000 Associate Medical Director, Beth Israel Medical Center/Singer Division Oct 2000-Dec -2003 Acting Chairman, Department of Pediatrics, Beth Israel Medical Center Jan 2004 -Present Chairman, Department of Pediatrics and Pediatrician in Chief of the Milton and Bernice Stern Department of Pediatrics/Beth Israel Medical Center March 2012-2013 Interim Chairman, Department of Pediatrics and Pediatrician in Chief St. Luke's and Roosevelt Hospital May 2013- Interim Chairman, Department of Pediatrics and Pediatrics in Chief St. Luke's and Roosevelt Hospitals 4. Medical License: 1985 162704 New York State 2003 25MA07694700 New Jersey 2. FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 5. Certification: 1985 Diplomate, National Board of Medical Examiners (289948) 1988 Diplomate, American Board of Pediatrics (ABP: 38147) 1990-1997 Diplomate, Sub-Board Critical Care Medicine, Amet·ican Board ofPediatrics (#000202) 1997-2004 Recertification in Pediatric Critical Care Medicine (ABP: 000202) 2001-2007 Recertification in General Pediatrics (ABP: 038147) 2002-2012 Recertification in Pediatric Critical Care Medicine (ABP: 000202) 2007-2014 Recertification in General Pediatrics (ABP: 038147) 2012-2022 Recertification in Pediatric Critical Care Medicine (ABP: 000202) Professional Society Memberships: 1988- Member, Society of Critical Care Medicine 1988- Fellow, American Academy of Pediatrics 1988- Pediatric Alnmni Association, SUNY, Health Science Center, Brooklyn, New York 1989- Member, New York Society of Pediatric Critical Care Medicine 1989- Member, American Academy of Pediatrics, Section on Pediatric Critical Care Medicine 1990- Montefiore Medical Center Alumni Association 1990- Albert Einstein College of Medicine Pediatric Alumni Association 1992- Member, American Academy of Pediatrics, Section on Injury and Poison Prevention 1992 Member, American Academy of Pediatrics, Section on Emergency Medicine 1995- Member, American Academy of Pediatrics, Section on Child Abuse and Prevention 1999- Member, American College of Physician Executives 2002-2007 Treasurer, New York Society of Pediatric Critical Care Medicine 6. Other Professional Activities: A. Intramural Activities and Committees 1984-1989 Pediatric Housestaff Education Committee 1988- Instructor, Pediatric Advanced Life Support 1989-1995 Lecturer, Advanced Cardiac Life Support 1990-1994 Hospital Utilization Review Committee, Montefiore Medical Center 1990-1992 Member, Faculty Student Senate, Albert Einstein College of Medicine 1990-1992 Member, Governance Council, Pediatric Private Practice Plan, Department of Pediatrics, Albert Einstein College of Medicine 3. FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 1991-1992 Secretary, Governance Council, Pediatric Private Practice Plan, Department of Pediatrics, Albert Einstein College of Medicine 1992-1996 Member, Pediatric Education Policy and Planning Committee Albert Einstein College of Medicine 1992-1996 Member, Montefiore Medical Center Cardiac Arrest Committee, Bronx, New York 1992-1993 Member, Residency Curriculum Subcommittee of the Division of Pediatric Education/Albert Einstein College of Medicine 1992-1993 Member, Chief Residency Subcommittee of the Division of Pediatric Education/Albert Einstein College of Medicine 1993-1996 Member, Pediatric Research Advisory Committee, Albert Einstein College of Medicine 1994-1995 Co-Director, Introduction to Research and Statistics Course for the Department of Pediatrics Fellowship Training Programs/Albert Einstein College ofMedicine 1994-1996 Member, Search Committee for the Director of the Division of Neonatology/Albert Einstein College of Medicine 1995-1996 Member, Governance Council, Pediatric Private Practice Plan, Department of Pediatrics/Albert Einstein College of Medicine 1995-1996 Director, Introduction to Research and Statistics Course for the Department of Pediatrics Fellowship Training Programs/Albert Einstein College of Medicine 1995-2001 Instructor, Problem Based Learning for Medical Students, Albert Einstein College of Medicine 1996 Chairman, Ad Hoc Committee on Promotions, Albert Einstein College of Medicine 1996M2004 Member, Ethics Committee, Beth Israel Medical Center/North Division 1996-2000 Member, Committee on Pharmacy and Therapeutics, Beth Israel Medical Center/North Division 1996-2004 Member, Executive Committee at Beth Israel Medical Center/North Division 1996M2004 Co-Chairman, Pediatric Continuous Quality Improvement Committee at Beth Israel Medical Center/North Division 1997-2004 Member, Infection Control Committee at Beth Israel Medical Center/North Division 1998-2000 Medical Student Preceptor for Third Year Pediatric Clerkship Albert Einstein College of Medicine 1998 Course Director, Pediatric Neurologic Emergencies, Roosevelt/St. Luke's Medical Center 2000-2008 Member, LICHJBI Pediatric Resident Committee 2000-2008 Member, LICHJBI Residency Review and Recruitment Committee 2001-Present Committee on Professors, Department of Pediatrics, AECOM 2002-2004 Member, Committee on Professorial Promotions, AECOM 2004-Present Member, Pediatric Quality Improvement Committee, Beth Israel Medical Center 2008-Present Member, Pediatric Medication Error Committee Beth Israel Medical Center 4. FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 MOUNT SINAI BETH ISRAEL ARTICLE 28 NETWORK DESCRIPTION Mount Sinai Hospitals Group, Inc. (MSHG), a not-for-profit corporation, is the active parent and co-operator of Mount Sinai Hospital (including its division, Mount Sinai Hospital of Queens), Mount Sinai Beth Israel, Mount Sinai Brooklyn, Mount Sinai St. Luke's, Mount Sinai Roosevelt and the New York Eye and Ear Infirmary of Mount Sinai. Mount Sinai Hospital (MSH) is located at One Gustave L. Levy Place, New York (New York County), New York 10029. MSH also has a division, Mount Sinai Hospital of Queens, which is located at 25-10 30th Avenue, Long Island City (Queens County), New York 11102. Mount Sinai Beth Israel is located at First Avenue at 16th Street, New York (New York County), New York 10003. Mount Sinai Brooklyn is located at 3201 Kings Highway, Brooklyn (Kings County), New York 11234. Mount Sinai St. Luke's is located at 1111 Amsterdam Avenue, New York (New York County), New York 10025. Mount Sinai Roosevelt is located at 1000 Tenth Avenue, New York (New York County), New York 10019. New York Eye and Ear Infirmary of Mount Sinai is located at 310 East 14tli Street, New York (New York County), New York 10003. The following table provides information on operating certificate numbers and PFI numbers for the above-referenced facilities: Operating PFI# Facility Name Certificate # Mount Sinai Hospital 7002024H 1456 Mount Sinai Hospital of Queens 7002024H 1639 Mowtt Sinai Beth Israel 7002002H 1439 Mount Sinai Brooklyn 7002002H 1324 Mount Sinai St. Luke's 7002032H 1469 Mount Sinai Roosevelt 7002032H 1466 New York Eye and Ear Infirmary of Mount Sinai 7002026H 1460 FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Limited Review Application. Schedule·LRA 10 _ State of New York Department of Health/Office of Health Systems Management Impact of Limited Review Application on Operating Certificate (services specific to the site) Instructions: "Current" Column: Mark "x" in the box only if the service currently appears on the operating certificate (OpCert) not including requested changes "Add" Column: Mark "x" in the box this CON application seeks to add. "Remove" Column: Mark "x" in the box this CON application seeks to decertifY. "Pro osed" Column: Mark "x" in the box corres ondin to all the services that will ultimately a ratel!orv/Authorized Service Code Current Add Remove Proposed Chemical Dependence - Rehabilitation --- 30 30 Chemical Dependence - Detoxification --- 31 31 Coronary Care --- 8 8 Intensive Care --- 36 36 Maternity --- 42 42 Medical/Surgical --- 504 504 Neonatal Continuing Care --- 14 14 Neonatal Intermediate Care --- 17 17 Pediatric --- 20 20 Pediatric ICU --- 5 -5 0 Psychiatric --- 92 92 Note: MSBI is concurrently submittim! a separate Limited Review Application for the decertification of all 20 inpatient pediatric beds at the HosDital for the same reasons as noted in this Aonlication. It is beinl! submitted under a senarate Application due to the different timeframes for decertification of beds. TOTAL 799 -5 794 Does the applicant have any previously submitted Certificate of Need (CON) applications that have not been completed inv~lving addition or decertification of beds? [giNo 0 Yes (Enter CON numbers to the right) (Rev. 717/2010} FILED: NEW YORK COUNTY CLERK 02/07/2024 02:07 PM INDEX NO. 151136/2024 NYSCEF DOC. NO. 30 RECEIVED NYSCEF: 02/07/2024 Limited Review Application Schedule LRA 12 ~ State of New York Department of Health/Office of Health Systems Management Assurances The undersigned, as a duly authorized representative ofthe applicant, hereby gives the following assurances: a) The applicant has or will have a fee simple or such other estate or interest in the site, including necessary easements and rights-of-way, sufficient to assut·e use and possession for the purpose ofthe construction and operation of the facility. b) The applicant will obtain the approval of the Commissioner of Health of all required submissions, which shall conform to the standards of construction and equipment in Subchapter C ofTitle 10 (Health) of the Official Compilation of Codes, Rules and Regulations ofthc State of New York (Title 10). c) The applicant will submit to the Commissioner of Health final wotking drawings and specifications, which shall conform to the standards of construction and equipment ofSubchaptel' C of Title 10, prior to contracting for construction, unless otherwise provided for in Title I 0. d) The applicant will cause the project to be completed in accordance with the application and approved plans and specifications. e) The applicant will provide and maintain competent and adequate architectural and/or engineering inspection at the construction site to insure that the completed work conforms to the approved plans and specifications. t) If the project is an addition to a facility already in existence, upon completion of construction all patients shall be removed from areas of the facility that are not in compliance with pertinent provisions of Title l 0, unless a waiver is granted by the Commissioner of Health, under Title I0. g) The facility will be operated and maintained in accordance with the standards prescribed by law. h) The applicant will comply with the provisions ofthe Public Health Law and the applicable pt·ovisions of Title 10 with respect to the operation of all established, existing medical facilities in which the applicant has a controlling interest. i} The applicant understands and recognizes that arty approval of this application is not to be construed as an approval of, nor does it provide assurance of, reimbursement for at1y costs identified in the application. Reimbursement for all cost shall be in acco1;dance with and subject to the provisions of Part 86 of Title 10. !1- q-;c.- Date Signature I Kenneth L. Davis, M.D. Name (Please Type) President and CEO, Mount Sinai Hospitals G1·oup Title (Please Type) (Rev. 71712010)